Non-ST-Elevation Acute Coronary Syndromes

September 29, 2014 by  
Filed under Acute Med, All Updates, EMS, Guidelines, ICU, Resus

The latest AHA/ACC guidelines on NSTEACS have been published ahead of print in Circulation.

Full text is available, and the Executive Summary is available here

Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al.
2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014 Sep 23. [Epub ahead of print]

Blunt traumatic arrest in kids

September 24, 2014 by  
Filed under All Updates, EMS, Kids, Resus, Trauma

Traumatic cardiac arrest outcomes are not great, but they’re not so bad that resuscitation is futile – a subject I’ve ranted about before.

The largest study on blunt traumatic arrest in children to date has been published, showing that 340 / 7766 kids without signs of life in the field survived to hospital discharge. Neurological status at discharge was not documented. However, this represents 4.4%, or in other words for every 22 blunt traumatically arrested children who underwent prehospital resuscitation, one survived to discharge. The authors describe this survival as ‘dismal’. It’s not great, but my take on it is that survival is possible and in most cases resuscitation should be attempted.

The authors state:

Based on these data, EMS providers should not be discouraged from resuscitating blunt pediatric trauma patients found in the field with no signs of life

While the major focus should be on injury prevention, it is worthwhile considering whether more advanced resuscitation in the field could be provided to further increase the number of neurologically intact survivors.

Survival of pediatric blunt trauma patients presenting with no signs of life in the field
J Trauma Acute Care Surg. 2014 Sep;77(3):422-6


BACKGROUND: Prehospital traumatic cardiopulmonary arrest is associated with dismal prognosis, and patients rarely survive to hospital discharge. Recently established guidelines do not apply to the pediatric population because of paucity of data. The study objective was to determine the survival of pediatric patients presenting in the field with no signs of life after blunt trauma.

METHODS: We conducted a retrospective analysis of the National Trauma Data Bank research data set (2002-2010). All patients 18 years and younger with blunt traumatic injuries were identified (DRG International Classification of Diseases-9th Rev. codes 800-869). No signs of life (SOL) was defined on physical examination findings and included the following: pulse, 0; respiratory rate, 0; systolic blood pressure, 0; and no evidence of neurologic activity. These same criteria were reassessed on arrival at the emergency department (ED). Furthermore, we examined patients presenting to the ED who underwent resuscitative thoracotomy (Current Procedural Terminology code 34.02). Our primary outcome was survival to discharge from the hospital.

RESULTS: There were a total of 3,115,597 pediatric patients who were found in the field after experiencing blunt trauma. Of those, 7,766 (0.25%) had no SOL. Seventy percent of the patients with no SOL in the field were male. Survival to hospital discharge of all patients presenting with no SOL was 4.4% (n = 340). Twenty-five percent of the patients in the field with no SOL were successfully resuscitated in the field and regained SOL by the time they arrived to the ED (n = 1,913). Of those patients who regained SOL, 13.8% (n = 265) survived to hospital discharge. For patients in the field with no SOL, survival to discharge was significantly higher in patients who did not receive a resuscitative thoracotomy than in those who did.

CONCLUSION: Survival of pediatric blunt trauma patients in the field without SOL is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.

Resuscitationist lessons from a self-protection master

August 28, 2014 by  
Filed under All Updates, Fascinomata, Resus

UCIt’s better to have it and not need it, than to need it and not have it

My great friend and fellow Brit Lee Morrison is in Sydney again, teaching people how to save lives. Like a resuscitationist. But Lee isn’t a health care worker. He is a professional self protection instructor and martial athlete. The lives he is teaching people to save are their own and those of their friends and families. Lee has travelled the world and taught a diverse range of professionals including law enforcement and military special forces personnel. His current world tour will include the Czech Republic, USA, France, Russia and Germany after Australia.

What does this have to do with resuscitation? In my experience, almost everything. Hitting someone in self defence is technically very easy. Doing a resuscitative hysterotomy is technically very easy. Being able to do either of those things under stress can be difficult or impossible for some people.

Those who strive to understand and cultivate the Mind of the Resuscitationist know the importance of preparation through simulation under stress; the need to acknowledge and control the physiological and emotional response to stress; the necessity to train outside ones comfort zone and minimise the gap between simulated and real situations by optimising the cognitive fidelity of training scenarios; and the requirement to access the right mental state in an instant in which failure is not considered to be an option.

People who do not wish to witness the discussion or demonstration of violence or who cannot stand swearing should stop now. Those of you who want to see mastery in action watch the video below of Lee teaching in Germany.

I want you to appreciate the following:

  • Presentation style – how to connect with an audience and fully engage them through humour, passion, emphasis, intelligent discourse, and detailed explanations that connect emotionally and physically as well as intellectually.
  • The loss of fine motor skill under stress (2 min 13 sec)
  • The mindset of determination (2 min 48 sec) – consider how this relates to the perspective of the resuscitationist prepared to do a resuscitative thoracotomy under stress
  • How to influence and win arguments in a conflict situation by being assertive but providing a face-saving get-out for the aggressor. I have applied this multiple times in the resus room and in retrieval situations. (4 min 11 sec)
  • Training honestly – maintaining safety but ‘doing it like you f—-ing mean it’. Get out of your comfort zone and make the discomfort as real as possible. (7 min 37 sec)
  • How to minimise the gap between your training and what you’re training for, when legal, moral, and safety restrictions prevent you from doing the actual task for real as a training exercise. Using fatigue, pain, and disorientation as perturbations so you learn to recognise and mitigate their effects. (9 min 19 sec)
  • Accessing a single mental state that provides focus and prevents distraction from discomfort (11 min 40 sec)

If the video made you feel uncomfortable ask yourself why. If it’s because you consider yourself to be above violence and find the subject matter, language, and humour to be distasteful, that’s your right to feel like that. But try to dig a little deeper and ask yourself whether there are potential situations in your life that could confront you with fear or pain that you could be better prepared for if you trained with a different mindset.

When the situation arises that demands life-saving action and you are tired, hungry, scared, and discouraged by opposing advice or opinion, do you have the self-knowledge and resilience to see it through? If you don’t know the answer to that, isn’t it time you found out?

You can find out more about Lee at Urban Combatives

Hexagonal storm on Saturn’s North Pole

August 11, 2014 by  
Filed under All Updates, Fascinomata

Comments Off

Our solar system is amazing and beautiful and the wondrous discoveries continue. Watch this video from the NY Times on Saturn’s northern storm, shaped like a hexagon and larger than Earth:

This line from the video is inspiring:

Rings of ice, in a dancing ribbon of Aurora, sitting smack on top of a six-sided hurricaine. Another jewel in the crown of the solar system’s most photogenic planet.

 

Not Your Average Conference

August 3, 2014 by  
Filed under All Updates

Comments Off

DevEM2014

An amazing conference program, amazing speakers, in an amazing part of the world:

Imagine a line-up that includes FOAM Master Joe Lex and Matt & Mike from the Ultrasound Podcast, and it isn’t even a SMACC event!

I wish I was going, but I already committed to speaking at a great conference elsewhere!

Listen to organisers Mark and Lee talk about this and last year’s fantastic DevelopingEM conference in Cuba:

Here Mark and Lee explain how it works and what to expect:

After the success of our last two conferences in Sydney and Havana we’re taking the DevelopingEM concept to Brazil where Emergency Medicine is quickly evolving as a new specialty.

Our core focus remains the provision of high quality clinically relevant critical care information and with an expanded program and the addition of Sambafest, a 2 day Ultrasound Workshop, run by the team at Ultrasound Podcast, we think this will be our best conference to date.

With an expanded program covering Adult Emergency Medicine and Critical Care, Paediatrics, Trauma, Global Health, Emergency Medicine in Brazil, a LLSA session covering a review of EM and Critical Care Literature and a unique Communication and De-escalation workshop we’re sure there’s something for everyone in our program.

Our 42 hours of education is accredited by ACEM and ACRRM and DevelopingEM is endorsed by IFEM and supported by ASEM so time will be a valuable addition to your yearly continuing professional development.

We’re also repeating the highly successful local delegate sponsorship system that allowed 65 Cubans clinicians to attend DevelopingEM 2013 free of charge. With our connections in the Brazilian Association of Emergency Medicine (ABRAMEDE), presentations on Emergency Medicine in Brazil by some of the leading EM practititioners in Brazil and continuous real time translation of presentations we hope to once again have a distinct local flavour to DevelopingEM 2014.

We have maintained our not for profit financially unsponsored model so you know your education will be untainted ’cause we know you like it that way.

 

Check out the program and register here

These guys are my prehospital & retrieval medicine colleagues and run the DevelopingEM project in a not-for-profit capacity. I have no financial interest in this or any other conference.

Profound hypothermia and no ECMO?

July 11, 2014 by  
Filed under Acute Med, All Updates, ICU, Kids, Resus

CPRsnow2sm

Patients in cardiac arrest due to severe hypothermia benefit from extracorporeal rewarming, and it is often recommended that they are treated at centres capable of providing cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO).

But what if they’re brought to a centre that doesn’t have those facilities?

If you work in such a centre do you have a plan, and are you familiar with what equipment you could use?

One option if you have an ICU is to provide extracorporeal warming using a haemofiltration machine used for renal replacement therapy(1). A double lumen haemofiltration catheter is inserted into a central vein and an ICU nurse can often do the rest, although some variables have to be set by the intensivist, often aided by a standard renal replacement therapy prescription chart. The machines are mobile and can be wheeled into the resus room (I have practiced this set up in resus). It might be worth discussing and practicing this option with your ICU.

Another extracorporeal option is to rig up a rapid infusion device such as a ‘Level 1′ to connect to arterial and venous catheters so that blood from the patient flows through and is warmed by the machine before being returned to the patient(2). Rapid rewarming has been achieved by this method but it requires some modification to the usual set up and so is much less likely to be a realistic option for most teams doing this on very rare occasions.

Less technical options are the traditionally taught warm saline lavage of body cavities such as the thorax and the peritoneal cavity. These can be achieved with readily available catheters and of course should be combined with ventilation with warmed gas and administration of warm intravenous fluid.

Thoracic lavage can be achieved with open thoracotomy or tube thoracostomy. One or two chest tubes can be placed on each side. One technique was described as:


Two 36 French chest tubes were placed in each hemithorax. One tube was placed in the fourth intercostal space in the mid-clavicular line. Another tube was placed into the sixth intercostal space in the mid-axillary line. Sterile saline at 39.0◦C was infused by gravity into each superior chest tube and allowed to drain passively through each inferior tube.(3)

Rapid rewarming at a rate of 6.8◦C per hour was achieved in an arrested hypothermic man using peritoneal lavage. It was done in the operating room with peritoneal lavage (saline 40◦C) with a rapid infusion system (Level 1) through two laparoscopic access sites. It was combined with external forced air rewarming and warm intravenous infusions(4).

Finally some devices manufactured for inducing hypothermia in post-cardiac arrest patients can also be used to rewarm patients, which might be endovascular devices, such as the Cool Line® catheter(5), or external, such as the Arctic Sun® Temperature Management System(6). It’s definitely worth finding out what your critical care services have as far as this equipment goes.

In summary, although the ‘exam answer’ for cardiac arrest due to profound hypothermia is often ECMO/cardiopulmonary bypass, in most centres that’s not an option. It’s helpful to remind ourselves that (1) other extracorporeal rewarming options exist and (2) non-extracorporeal techniques can provide rapid rewarming.

 

1. Spooner K, Hassani A. Extracorporeal rewarming in a severely hypothermic patient using venovenous haemofiltration in the accident and emergency department. J Accid Emerg Med. 2000 Nov;17(6):422–4. Full text

2. Gentilello LM, Cobean RA, Offner PJ, Soderberg RW, Jurkovich GJ. Continuous arteriovenous rewarming: rapid reversal of hypothermia in critically ill patients. The Journal of Trauma: Injury, Infection, and Critical Care. 1992 Mar;32(3):316–25 PubMed

3. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest — report of a case and review of the literature. Resuscitation. 2005 Jul;66(1):99–104. PubMed

4. Gruber E, Beikircher W, Pizzinini R, Marsoner H, Pörnbacher M, Brugger H, et al. Non-extracorporeal rewarming at a rate of 6.8°C per hour in a deeply hypothermic arrested patient. Resuscitation. 2014 Aug;85(8):e119–20. PubMed

5. Kiridume K, Hifumi T, Kawakita K, Okazaki T, Hamaya H, Shinohara N, et al. Clinical experience with an active intravascular rewarming technique for near-severe hypothermia associated with traumatic injury. Journal of Intensive Care. BioMed Central Ltd; 2014;2(1):11. link to abstract

6. Cocchi MN, Giberson B, Donnino MW. Rapid rewarming of hypothermic patient using arctic sun device. Journal of Intensive Care Medicine. 2012 Mar;27(2):128–30. PubMed

When to Stop Resuscitation

July 9, 2014 by  
Filed under Acute Med, All Updates, EMS, Guidelines, ICU, Kids, Resus, Trauma

Comments Off

My talk at the SmaccGOLD conference in March 2014

Cliff Reid – When Should Resuscitation Stop from Social Media and Critical Care on Vimeo.

Here are the slides:

Down with “down” time!

May 11, 2014 by  
Filed under Acute Med, All Updates, EMS, Resus

CPR-icon2A man in his 40s has a witnessed collapse and CPR is immediately started. Paramedics are on scene within 5 minutes and initiate advanced cardiac life support. He has refractory ventricular fibrillation which degenerates to asystole. He arrives in an emergency department where, with good ongoing CPR, he appears reasonably well perfused and even demonstrates some spontaneous movements and reactive pupils. He is placed on a mechanical CPR device and activation of the cardiac cath lab is requested. The patient has been in cardiac arrest now for 32 minutes. The cardiology fellow appears and asks: ‘what’s the down time?’

What’s the right answer? Would you say ‘half an hour’? ’32 minutes’?
And does it matter? Why is the cardiology fellow asking? Does she have an arbitrary cut off in mind, over which emergency coronary reperfusion will be denied?

I think there are several problems with conversations like these.
The first, is what does ‘down time’ even mean?
The second, is how relevant is a cardiac arrest time interval to prognosis in an individual patient?
The third, is what is the significance of any time interval in a patient who at the time of assessment has some signs that CPR is providing some perfusion and there is some evidence of brain function?

Let’s take the first. The definition of ‘down time’ does not appear to be standardised:

In this publication it appears to refer to the time before resuscitation is commenced, where it is demonstrated to be prognostically important.

Similarly, in this medical dictionary, it is defined as the ‘temporal duration from cardiac arrest until beginning cardiopulmonary resuscitation or advanced cardiac life support.

However, a post in Life in the Fast Lane defines it as ‘time to return of spontaneous circulation

This appears to agree with The New South Wales Government’s Intensive Care Monitoring and Coordination Unit who define it as ‘the time from when a person’s heart stops beating to the time it starts beating again

Yet another definition is used in King County, Washington, where it is defined as ‘the time interval from collapse to call 911‘.

So the first thing is to clarify what we’re talking about: “This patient received immediate bystander CPR. He has had resuscitation for 32 minutes”. My friend in the UK, nurse resuscitationist Fernando Candal Carballido, coined the term ‘Time of Supported Circulation‘, or TOSC. I quite like this and think it could catch on.

The next question is so what? What if it was 90 minutes? At what point do we declare futility? This is where I believe the game has changed. Multiple survivors of prolonged resuscitation are springing up in the news and in the literature. Particularly in the subgroup of patients with minimal comorbidity, early CPR, and who receive circulatory support via ECMO or mechanical CPR while they undergo coronary reperfusion.

For a great example of a prolonged CPR survivor, check out paramedic Wayne Schneider’s story,

…or listen to Steven Bernard describe amazing results from ECMO used in Melbourne in the CHEER study, which includes survivors of over two hours of CPR.

So, in summary:

  • Be clear on your definitions when communicating with colleagues. ‘Down time’ does not appear to have a standard definition, so I would avoid its use.
  • Some patients without comorbidities who have had early bystander CPR may survive despite long periods of CPR (or ‘TOSC’), provided the underlying cause can be treated or is reversible.
  • ECMO and even more widely available mechanical CPR devices are extending the period in which these causes can be addressed.

Emergency Medicine – A Great Job

May 10, 2014 by  
Filed under All Updates

Comments Off

I was asked to speak at the Australasian Conference for Emergency Medicine‘s Annual Scientific Conference in Adelaide in November 2013. The title they gave me was ‘What a great job’. It was a great opportunity for me to explore some of the literature around what makes people happy, and whether emergency medicine has the ingredients to do that. It does. But not if you do too much.

The College has generously made available many of the conference talks as FOAM here.

Here’s my talk. The slideset is below.

2013 ASM: Dr Cliff Reid – What a great job from ACEM Digital Media on Vimeo.

Time to change thinking on ‘cricoid pressure’

April 22, 2014 by  
Filed under All Updates

I don’t like cricoid pressure. Some people do. There is insufficient evidence that it is of any benefit. There is some consistent evidence that it worsens laryngoscopic view.

In my clinical practice of critical care in and out of hospital, I can’t afford to risk delaying the securing of my patients’ airways with a procedure in which in my view the risks of harm outweigh any unproven chance of benefit.

I had erroneously thought after many online ‘debates’ that the critical care community had settled on a compromise – if you want to use it great, just take it off if it’s causing a problem. If you don’t want to use it, then that’s equally fine.

However a Google Plus conversation last week ignited a storm! There was a suggestion that cricoid pressure represented a ‘standard of care’, and that not to use it in a critical care intubation would potentially invite legal proceedings, catalysed by colleagues prepared to testify against those of us who have carefully weighed the balance of evidence and selected what we feel is the best approach for our patients.

I wrote a post to challenge the very thinking that what might be considered a ‘standard of care’ in elective anaesthesia in some guidelines should ever be applied to a critical care airway. I proposed a tongue in cheek change of terminology to emphasis what we know about cricoid pressure in the critically ill: that it can delay intubation, distort and compress the airway, and move rather than compress the oesophagus (although I concede the latter point may be irrelevant in terms of CP’s proposed mechanism).

Some people got upset. I reworded the post and added a big fat disclaimer to avoid any perception of ad hominen attack. I wanted to attack and ridicule the procedure, not its proponents. I still got attacked using some bizarrely offensive comparisons by people you would expect to know better. It got ugly.

The combination of support by some people I hold in very high regard and a currently crazy schedule (I’ve been in the UK for three hours having just travelled from Australia) meant the post stayed up for a while until I could consider the feedback. I still haven’t read it all. But I’ve read enough.

I respect the people I disagree with. I respect absolutely their right to hold different views from my own. But I don’t respect all their views, and I don’t necessarily think people have a right not to be offended by my views. However if the WAY I EXPRESS those views causes UNNECESSARY offence I have to reconsider my message.

The science around cricoid pressure is there in the literature. The arguments that it can acceptably be discarded in critical care are powerful. If we need a new acronym it doesn’t need to be one that can be pronounced and construed in a way different to that which I’d envisaged. As Dr Brent May so insightfully put: ‘You can’t emphasise a syllable on Twitter‘.

I want to thank EVERYONE who provided constructive feedback on and off social media. I apologise unreservedly to anyone offended by the post. It’s gone. The battle against unthinking enforcement of a potentially harmful technique goes on, but the unwitting offence of innocent parties is not an acceptable consequence. I will try to be more intelligent in subsequent debate.

Cliff

Next Page »