PHEMCast have put together a great podcast which can guide you through the procedure and get you started.
Check out the website for other PHEM podcasts or subscribe on your podcast manager.
'Sydney HEMS' is the Pre-Hospital and Retrieval Team for the New South Wales Ambulance Service. Members of the team: Cliff Reid, Karel Habig and Geoff Healy have got together to produce some great introductory podcasts. Although aimed at those starting in PHEM, I found listening to three well respected experts discussing some of the basics in their speciality a really valuable experience.
Easiest way to listen is to subscribe through iTunes or plug:
http://feeds.feedburner.com/GSAHEMS
into the 'add URL' option on a podcast manager.
You could also just download from the Website: https://sydneyhems.com/category/podcasts/
As ever the Masters of #FOAMed Ultrasound make it look easy!
In our ED we still need to follow our local protocol, but the evidence discussed in these podcasts suggests things may change, especially in younger patients, and US may be the first line investigation.
No harm in trying to predict what the CT KUB will show and getting your eye in!
Another great summary of recent papers by the team at HEFTEMcast.
From ABCD2 Scores (are they actually useful?) through to surgical airways with a biro....
Check it out here: Papers of June Podcast Summary
http://intensivecarenetwork.com/understanding-lactate-paul-marik/
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.
http://www.ultrasoundpodcast.com/wp-content/uploads/2013/02/image.jpg
More great meducation from @ultrasoundmd and @ultrasoundpod on lung USS. They are doing a series on ultrasound basics which is an awesome way for a beginner to recognise the potential of their new skills.
Lung US is useful both in the resus room and triage guiding initial treatment and further investigation. Its quick, easy and you can practice your technique while waiting for the XR machine to power up........SO 19th century!
Check out their other basics podcasts on lines and renal US.
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.
Be sure to check out the whole series on EMCrit:
Laryngoscope as a murder weapon: Oxygenation Kills part 1 & part 2
More Paeds this week!
I have always found the ALTE (Acute Life Threatening Events) concept a bit frustrating:
“an episode that is frightening to the observer and that is characterised by some combination of apnoea (central or occasionally obstructive), colour change…marked change in muscle tone
(usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died.”
It seemed vague enough to include almost anything from the obviously worrying to the obviously benign and advocated a lot of admissions that seemed ovecautious.
This Month The American Academy of Paediatrics released a clinical practice guideline which recommends a different strategy which is worth being aware of - and discussing with our paeds collaegues.
Its covered excellently by FOAMCast and Dont forget the bubbles.
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!
So its a while since we highlighted any great PEM learning sites and I stumbled across pemplaybook.org when this episode appeared on ERcast.
They put forward an intuitive structure to the assessment of the sick infant that appeals to me more than the usual ABCD. If you like mnemonics you're gonna love it..... Check the webpage for the notes - very helpful.
The only caveat is that I don't think I would rush to do ABGs to pick up congenital heart disease. I was trained to start with 4 limb BP and sats..... (while frantically calling for help) but I'd be interested to hear any other approaches.
Quick 5 min tutorial on how to measure optic nerve sheath diameter as a marker for raised ICP.
Obviously having learnt that you need to know what to do with it.......
Check out BROOME DOCS for the low down of where the research says we're at.
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:
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.
Lovely vodcast from WesternSono introducing you to distal radius reduction review using Point Of Care Ultrasound (POCUS) and also using POCUS in haematoma blocks. A great way to develop my skills in US which could be transferable into other areas eg sternal US.
In the future I imagine telling the medical students anecdotes about how we used to irradiate patients to see if the fracture was back to normal while pulling my portable US out of my pocket........ *drifts off into day-dream*
Great thought provoking discussion about how we use decision rules in the ED. Featuring Dr. Salim Rezaie of R.E.B.E.L. EM.
EM Cases produce excellent meducation podcasts from Canada. Their work is great quality, highly recommended and needs to be on your commuting podcast list!
Check out the EM Cases website for the shownotes and subscribe to the podcast.
Background: The electrocardiogram (ECG) is one of the most useful diagnostic studies for identification of acute coronary syndrome (ACS) and acute myocardial infarction (AMI). The classic teaching is ST-segment elevation myocardial infarction (STEMI) is defined as symptoms consistent with acute coronary syndrome (ACS) + new ST-segment elevation at the J point in at least 2 anatomically contiguous leads of at least 2mm (0.2mV) in men or at least 1.5mm in women in leads V2 – V3 and/or at least 1mm (0.1mV) in other contiguous leads or the limb leads, in the absence of a left bundle branch block, left ventricular hypertrophy, or other non-acute MI ST-segment elevation presentations. Unfortunately, the ECG may be non-diagnostic in nearly half of all patients who initially present with AMI. There are also STEMI equivalent patterns that are caused by occlusion of the coronary arteries that place a significant portion of the left ventricle at jeopardy and result in poor outcomes. This review article focused on 5 under recognized high-risk ECG patterns in the ACS patient that result in poor outcomes including malignant dysrhythmias, higher rates of cardiogenic shock, and death.
Clinical Bottom Line: It is important to recognize the above 5 patterns as these are high risk ACS patients because a significant portion of the left ventricle is at jeopardy. Only 4 of the above diagnoses require activation of the cath lab immediately and the 5th requires consultation of interventional cardiology.
Cath Lab Activation:
Interventional Cardiology Consultation:
Keep current with a great summary of recent papers from Heftemcast.co.uk.
Great.....another viral epidemic on the loose for us to get our heads around......
Lucky that:
1) its an excuse for a musical interlude
2) St Emlyns have done a summary in blog form- Click Here
Happy listening!
Salim Rezaie and the crew at R.E.B.E.L EM have kindly published a nice appraisal of a recent Retrospective study seeking to externally validate the Modified Sgarbossa Criteria. These rules guide interpretation of ECG ischaemia in LBBB.
This article gives a useful run down of the criteria and how to use them, as well as taking us through a critical appraisal - useful for anyone approaching FCEM.
Check out the blog here: Modified Sgarbossa Criteria: Part Deux
Great Post and Podcast from Scott Weingart featuring Ashley Shreves on the practical steps to introduce these discussions in an ED setting.
“End of Life Conversations are Hard
We stumble, we stutter, we say things that derail the discussion when we have a patient at the end of life. But how do we learn to do better? We model good behavior. But in order to do that we need to hear good discussions. I listened to Ashley Shreve’s amazing SMACC Chicago talk: What is a Good Death?
After listening, I wanted to bring Ashley back on to really get into the nitty-gritty of the semantics of End of Life discussions. Ashley has been on the EMCrit podcast before discussing Critical Care Palliation. Now lets hear from here again…
Tidbits I pulled out of the Podcast
The three patients that will spur Ashley to try to have these discussions:
1. Advanced Cancer or Terminal Disease with Instability
2. Advanced Frailty/Dementia with Instability
3. Advanced Physiological Age (>85 y/o) with Instability
Start with, “I’m so worried about your family member,” and see the response
Then, “Tell me how things have been going with your family member”
Technique: Ask, Tell, Ask, Tell
Know the trajectories of care for the diseases we deal with
Does that mean you will do nothing? No, we actually want to intensify the treatment, with a focus on peace and dignity
We don’t want to artificially prolong the dying process
Vitalists comprise 5-10% of the population, you are unlikely to convince these folks in the ED
What if things don’t get better?”
— http://emcrit.org/podcasts/semantics-end-of-life-discussions/
