Foam in review
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FOAM in Review
Kane Guthrie
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FOAM from 2012
• The review:– 189 different EMCC blogs & podcasts
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Crowdsourcing
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The Big FOAMed Hit’s
Of 2012
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The Popular OnesEMCrit DSI Best use of the Bougie
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Thought Provokers
& Game Changers!
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LMA in Cardiac Arrest • Does the LMA decrease cerebral blood flow?
• Using FOAMed to challenge the science!
http://bit.ly/XGYcv9
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LMA in Cardiac Arrest
• They didn’t buy it!• Used MRI to show LMA doesn’t impede flow!• Short paper response - rejected to letter form• So they used FOAMed instead!– Blog post, videocast & podcast discussion!
• LMA’s are safe in critically ill.
http://bit.ly/XGYcv9
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The Man who made Sepsis Sexy!
NYC STOP Sepsis Collaborative
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Sepsis in the ED
Lessons:– Time sensitive disease - High mortality– Needs early recognition– AB’s & fluids within 1 hour– Use lactate to find the cryptic cases– Non invasive approach is effective
http://emcrit.org/severe-sepsis-resources/
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Ketamine or KetaMinh
Who’s using it more because of Minh?
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Ketamine or KetaMinh• What is it good for?– Agitation/Aggression/Analgesia– Procedural sedation – Antidepressant– Hypotensive patients– Chronic pain – The DSI approach
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PCAs in the ED• Review of 2 studies!• Provide less-labor intensive analgesia• Better pain scores• Few more adverse events!– Nausea, vomiting, pruritis
• Worth it in some painful conditions!
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Critical Care Palliation
“When we can’t be aggressive with our resuscitation – we need to be aggressive with our palliation!”
http://emcrit.org/podcasts/critical-care-palliation/
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Critical Care Palliation
3 things never to say:
1. “Do you want us to do everything?”2. “Do you want us to resuscitate her?”
3. “I am so sorry, there is nothing more we can do”
http://emcrit.org/podcasts/critical-care-palliation/
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Tranexamic Acid
The FOAMed world ask why we aren’t using it?
– Its cheap! – Its an old drug!– But it works!– ?prehospital drug
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Pressure Poisoning
• Lung protective ventilation – Meta Analysis• Not just in ARDS!• Lower tidal volumes = better outcomes
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Pressure Poisoning
Start with:• 6-8ml/kg by IBW for all intubated ED patients
And protect those lungs!
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Hypoxic Patient?
Needs lots of O2?
Not for Intubation?
What to do?
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High Flow Nasal O2
http://emupdates.com/2012/03/01/the-high-flow-nasal-cannula-in-the-emergency-department/
• Give ^60L/02/min• Enable 100% 02, with 5/PEEP• Humidified• Great for NFI pts• More comfortable NIV• Use for DSI!
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PPI & Upper GI Bleeder!
• Face validity of using PPI’s• 750 million per/yr USA
• Systematic R/V -Cochrane• 2000 Pts
http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/
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PPI & the Upper GI Bleeder!
No difference in:• Mortality, rebleeding, need for surgery!
http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/
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The Best Tricks of the Trade!
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Difficulty feeding the NGT tube?
• Try the SCANCRIT manoeuvre!
http://www.scancrit.com/2012/05/30/scancrit-manoeuvre/
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Opioid Induced Constipation = Naloxone
• Give 2mg Naloxone PO• Mix with lactulose/colonlytely• Doesn’t induce opioid withdrawal!
http://blog.ercast.org/2012/02/the-constipation-manifesto/
=
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Superglue for CVCs• Need to secure that ART line or CVC during a
resus?Forget this: Try this:
http://bit.ly/Sf1sXY
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Need to Chemically Cardiovert SVT?
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Combine Adenosine with the Flush
• Use 20ml syringe• Draw up adenosine & flush together• Administer by fast IV push• Doesn’t reduce effectiveness!
http://academiclifeinem.blogspot.com.au/2012/12/trick-of-trade-combine-adenosine-and.html
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Nebulised Naloxone
• Worried about acute withdrawal with IV naloxone?
• Still got some respiratory effort?• Feel you need to do something?• Gives “gentle & effective” reversal?
Try 2mg naloxone, 3mls saline in a neb!
http://www.thepoisonreview.com/2013/02/01/nebulized-naloxone-in-opiate-intoxication/
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Stabilising Mandibular Fractures• Splinting mandibular dislocation/fracture
• Easy as
• Putting them in a stiff neck collar!
http://academiclifeinem.blogspot.com.au/2012/05/trick-of-trade-stabilizing-mandibular.html
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A Dose of Dex
• Casey been doing it for a while!• Cochrane then decided to agree with him:Benefits: • Reduction of pain• Early onset - 24hours• Same Kids vs Adults• No difference Bact vs Viral
http://broomedocs.com/2012/12/a-dose-of-dex/
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Ruling & Managing the
RESUS ROOM
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Life, Limb & Sight SavingProcedures
• Published in emj & Resus.Me• Questions if we’re ready to perform:– Time Critical Interventions
Highlights metacompetence:• Ability to apply the intervention @ the right time!
http://resusme.em.extrememember.com/?p=6707
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The Usual State of Readiness
• Being ready to act with life-saving maneuvers• Managing your own catecholamine's
Being ready 1. Cognitively2. Materially
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
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The Usual State of Readiness
1.Cognitively• Invisible simulation • Develop & prepare plans/scenarios in your
mind!• Knowing what you need to know
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
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The Usual State of Readiness
2. Materially • Equipment you need• When you need it• Where you need it
• Checking your equipment yourself!
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
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Mind of the Resuscitationist
• Being at the sharpest end of EM• Making things happen• Controlling your environment• Science of human persuasion • Standing like a leader
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Owning the Airway in 2012
Been dominated by:• From DL to VL
• To Human Factors & CRM• & Tools and Techniques
• Then LMAs, retrogrades, bougies, & airway aids –all through to the surgical airway!
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The Vortex
Changing the way we approach the difficult airway
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The Vortex
• “High stakes cognitive aid”– Simple enough to be recalled– Flexible enough to be use in any context
• Train staff in unanticipated difficult airway• Using single, simple, universally applicable
template
http://www.vortexapproach.com/Vortex_Approach/Vortex.html
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The FOAM Checklists
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EMCrit Intubation
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EM Updates Intubation Checklist
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EMCrit Post-Intubation Package
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EM Updates Asthma
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In Summary
FOAMed in 2012 was all about:• Airway management/devices• Teaching us to use Checklist• How to Rule the Resus Room
FOAMed showing how to practice medicine in the future!
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Questions
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Thank-you
May the FOAM be with you!