#FOAMed of the Week: Understanding Lactate via SMACC15 and @EMcrit



Paul Marik did a great talk at SMACC Chicago seeking to change the way we understand lactate. It makes great listening and definately changed the way I think. Check out the talk and the slides at Intensive Care Network.

Main Take Homes:

– The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis.
– Lactate is produced physiologically and is a precursor for gluconeogenesis.
– During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain.
– At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion.
– Adrenaline promotes lactate production
– Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock
– Lactate is a survival advantage!

Scott Weingart posted a SMACC Back Wee on why we should stop and think before throwing ditching our addiction to measuing lactate.... listen here: EMcrit.

So should we stop measuring lactate?  I think not, its useful as a marker of unwellness and can help guide our investigation. Its not black and white however. Having a better understanding of the physiology helps us navigate the greys of real life medicine.

#FOAMed of the Week: Laryngoscope as a Murder Weapon via EMCrit

The final part of Scott's excellent series on intubation in critically unwell patients. Feel more confident on your knowledge in how to deal with our sickest patients.

#FOAMed of the Week: Blood Products and TXA via @GAS_CRAIC (David Lyness)

ED Rotem got you a bit confused about your blood products? Wish you could remember some haematology? Whats the craic with TXA anyway?

#FOAMed to the rescue:

Brilliant summaries of blood products and how we use TXA from propofology.com by Dr David Lyness an anaesthetic trainee in the UK. Theres loads more stuff on the website so make sure you check it out!


New sepsis definitions were released in Febuary and got a mixed reception in the FOAMed world. 

Thankfully EMCrit pulls together some useful reading to get you up to speed with things: 

Firstly you could read the (free) JAMA paper .

Secondly you can read or download various FOAMed discussions on the topic: 


#FOAMed of the Week: @HEFTEMCAST turns medical comedy on its head in their podcast on needle thoracostomy

OK......, if black humour isn't your thing then maybe the video isn't entertaining.........HOWEVER the Team at heftemcast.co.uk have done a very interesting review of a resus classic - the needle thoracostomy. Could we be doing it at a better site?

Check their webpage: http://www.heftemcast.co.uk/needle-thoracostomy/ for all the show notes and evidence plus subscribe and rate the podcast.

#FOAMed of the Week: Sepsis SMACCdown via EMcrit

SMACC Chicago, brought to your armchair in dark n stormy Edinburgh. Viva la #FOAMed

An all-star panel discuss the burning issues in sepsis right now. Hosted by Chris Nickson and I, the conversation on the controversial aspects of sepsis was lubricated with on-stage alcohol (my idea!)

Mervyn Singer (research guru, sepsis expert and self-proclaimed Sex-God) and Paul Marik (iconoclast and dogma-basher) reveal just how hard it is to describe what sepsis is. Flavia Machado (intensivist and researcher) brings common sense and the perspective from South America, representing middle-income countries. Kath Maitland (author of FEAST, African-based paediatrician and clinical trialist) talks about sepsis management issues in Africa, where sepsis strikes its biggest global impact. Heavyweight researcher and clinician John Myburgh, argues that the word “sepsis” should be removed from our language and turns the paradigm on its head, arguing for a more pragmatic approach to sepsis management. Simon Finfer (crit care clinician, clinical trialist, voice of reason) describes the history, the good, the bad and the ugly about the Surviving Sepsis Guidelines, and some of the controversy surrounding them.

There’s a fascinating, very high level discussion on antibiotics which is not as clear cut as you might imagine. You couldn’t discuss fluids without talking about fluids and this panel features several world experts on this topic. Kath Maitland’s insights from FEAST, combined with the opinions of the rest of the panel will hopefully leave you an informed agnostic.

— http://emcrit.org/podcasts/sepsis-smaccdown/

#FOAMed of the Week: Acute Heart Failure via heftEMcast.co.uk

An excellent EBM based summary of the management of Acute Heart Failure for UK based EM trainees. Podcast below, but go to the website and subscribe to the podcast to get the full warm glowing feeling of knowing your up to date in an EM staple. 

heftEMcast is produced by the Heart of England NHS Trust Emergency Department. They aim to help keep our practice up to date with the latest EBM. 

#FOAMed of the week: ACID-BASE EMCrit Style - All time classic!

This we're going back to some pretty old posts from EMCrit - but an all time classic!!

Acid Base is a traditional brain melter for me and these podcasts have been amazing in helping get to grips with it from the ground up. Its in...... (gulp) 5 parts....BUT there was a recent related post from EM Nerd (Rory Spiegel) on EM Crit talking through the equally confusing anion and osmolar gap

Click the links below to go straight to the relevant EMCrit page with all the associated show notes, or to get started watch the videos below. 

One things for sure......we'll all gonna be a lot....SMARTER! 




ACID BASE Part IV: (Fluids)

ACID BASE Part V: (bicarb)

#FOAMed of the Week: #weneedtotalkaboutLACTATE via stemlyns

Another publication from the illustrious EMERGE landed on my doormat on Friday, this time exploring the utility of lactate in the Emergency Department. Yet my understanding of lactate was turned on its head at SMACC Chicago, and it's head has never been the same since.....

Lactate NOT an acid?  Lactate NOT just caused by tissue hypoxia?

There's no doubt lactate is invaluable in assessing critically ill patients, but if we are to use it more, shouldn't we understand it better?

Another chance for #FOAMed to shine, as St Emlyns step up (again) in the hour of need. Richard Carden (EM Trainee) writes an excellent blog covering dead parrots, whoop whoops, AND some physiology my brain can actually digest. 

Check out the blog here: Lactate = LactHATE

Don't forget to look at the links at the bottom of the article and also look out for the SMACC Chicago talks on the same in the future. 

Viva la #FOAMed

Hemodynamic Management of Massive Pulmonary Embolism via emcrit.org



 A great summary of the pathophysiology and management of Massive PE. 

emcrit.org is Scott Weingart's exploration of all things ED critical care and resuscitation.

Check out his website for one of the most amazing, free, medical education resources available on line.

Always check the comments section to hear what the international EM community has to say. 

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