11/1/2014

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Everything I do is Off-Label!

JustThe

Pearls

This is the ultimate

lecture for the ADHD emergency

physician.

11/1/2014

2

>20 Tipsin

60 Minutes

You’rerepeatin’yourself…

½ Trauma½ Medical Arrest

Crit Carein The

Trauma Bay

Case

11/1/2014

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Hypotensivein theField

HR 96BP 180/20

Sat 89% NCRR 22

GCS 14 (-1 Eyes)Moves Ext x 4

What doyou think?

IgnoreHR

Resuscitation. 2010 Sep;81(9):1142; Resuscitation 2011;82:556; J Trauma 2009;67:1051; BMJ 2004;328:451; J

Accid Emerg Med 1995;12:1; J Am Coll Surg 2003;196:679; J Trauma 1998;45:534; J Trauma. 2011;71: 789–792

Low or normal HRs are not on their own

reassuring in sick trauma pts @emcrit

11/1/2014

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Ignore InitialAutomated BPs

J Trauma. 2003;55:860 863

RepTime

Don’t believe the 1st

few BPs in sick trauma patients;

check your rep time@emcrit

So, if you can’ttrust the initial

vitals…

ETCO2 Low=Badness

11/1/2014

5

<C>ABC

Push on BellySqueeze Pelvis

Feel Feet

Pelvis MovesUnder Your Hands

Bind It!

11/1/2014

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Better thanExFix

JACS 2007;204:935

Orthopodshave nothing to

offer the crashing trauma patient

Is Sheetingas Good?

Can youMake Things

Worse?

Pelvic Binding: Early and Often @emcrit 50/30

11/1/2014

7

CavitiesMass Trans

AirwayMonitoring

Cavities:Where’s That

Bleed

ChestIntra-PRetro-PThighStreet

ChestIntra-P

Retro-PThighStreet

EmpiricChest Tubes

11/1/2014

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FingerThoracostomy

200 ml Blood on LNothing on R

CT on Left

ChestIntra-P

Retro-PThighStreet

FASTLiver Tip

with Patient inTrendelenberg

11/1/2014

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When the FAST really matters, RUQ Liver

tip with Trend. is the money! @emcrit

ChestIntra-P

Retro-PThighStreet

CavitiesMass Trans

AirwayMonitoring

Mass Trans:Hemostatic Resus

11/1/2014

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PRBC/Clotting Factors

1:1vs.1:2

PROPPR Trial

Type O PRBCThawed AB Plasma

Should be in the Trauma Bay

Scores >4 Units in the1st Hour

11/1/2014

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ABC Score

LLS Score

TXA

EarlyCryo

RoTEM/TEGDirected

Care

11/1/2014

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The Riseof the

Concentrates

FluidChoices in

Sick TraumaPatients

Warm Under Pressure

Containing clotting factors or

oxygenCalcium

11/1/2014

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90/50after

2 PRBC2 FFP

CavitiesMass Trans

AirwayMonitoring

MEDs:Ketamine

Rocuronium

Hypotensive intubation meds:

high-dose roc, low-dose ketamine.

@emcrit

CavitiesMass Trans

AirwayMonitoring

FemoralArterial Line

Shock 40(6), December 2013, p 527–531

11/1/2014

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UltrasoundCFA notthe SFA

Yes, it’s okin a pelvic fx

MAP 48

ResusGoal?

PermissiveHypotension?

11/1/2014

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MinimalNormotension

MAP >=

65and perfusing

May be 50very soon

J Trauma 2011;70:65250 vs 65

<65give the fluid of

trauma

>65eat away at the

adrenals

Fentanyl50-100mcg

J Trauma. 2002 Jun;52(6):1141-6

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At 1 mgpt is warm, perfusing &anesthetized

What aboutTBI?

Some would saySBP>90

We have a bedsidetest for

Increased ICP

Ocular ultrasound is a bedside test for ICP elevations in trauma

patients. @emcrit

11/1/2014

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90/506 PRBC4 FFP

1 Pack Plt1 Pack Cryo

Where should we go now?

ORvs.IR

WeShouldn’tHave to

Choose

Resuscitation with Angiography, Percutaneous Techniques and OperativeRepair

Can J Surg. Oct 2011; 54(5): E3–E4.

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RAPTOR: we should not have to choose

between IR and OR. @emcrit

40/20 60/40

BedsideIntervention? REBOA

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ResuscitativeEndovascular BalloonOcclusion of theAorta

From Megan Brenner

REBOA: vascular control without the

big cut—coming to a trauma center near

you. @emcrit

120/80More fentanyl andto RAPTOR Suite

for Angio

11/1/2014

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Review

Low or normal HRs are not on their own

reassuring in sick trauma pts @emcrit

Don’t believe the 1st

few BPs in sick trauma patients;

check your rep time@emcrit

Pelvic Binding: Early and Often @emcrit

When the FAST really matters, RUQ Liver

tip with Trend. is the money! @emcrit

Hypotensive intubation meds:

high-dose roc, low-dose ketamine.

@emcrit

11/1/2014

21

Ocular ultrasound is a bedside test for ICP elevations in trauma

patients. @emcrit

RAPTOR: we should not have to choose

between IR and OR. @emcrit

REBOA: vascular control without the

big cut—coming to a trauma center near

you. @emcrit

Cookbook

11/1/2014

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Nihilism

ACLSPush

hard & fast

TrulyAdvanced

Cardiac Life Support for

Resuscitationists

t

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Max Harry Weil

Disease-a-Month 1997

Airway

Convert to Tube ASAP

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Custom Bent Bonfils Fiberoptic Stylet

Breathing

GrossmanOn Combat

Hook them to the Ventilator

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Set Peak Pressure Limit to > 100 cm

H20

Set therate low

Circulation QualityCompressions

What about depth?

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EliminatePeri-Shock

Pause

ROC PrimedResus 2014;85:336

Look-ThroughRhythm Analysis

Crit Care Med 2013;41:1782LINC - JAMA. 2014;311(1):53-61

Sandra Ware on resus.me

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STEMIs go to Lab; Even if

Coding

Circulation 2012;126(13):1605

Drugs

Epi

The PACA Trial: Jacobs et alResuscitation. 2011;82(9):1138

VSE

JAMA. 2013;310(3):270Arch Intern Med 2009;169(1):15

Esmolol

Emergency Department Use of Esmolol in Refractory Ventricular Fibrillation

--Driver, Plummer, Smith

Nitroprusside?

Prolonged Adult Cardiac Arrest With Enhanced Cardiopulmonary Resuscitation and Sodium

NitroprussideYannopoulos’ Group

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Monitoring Femoral Arterial Line

Epi Dosing byDBP

Resuscitation 2013;84:696 | Crit Care Med 2013;41:2698JAMA 1990;263(8):1107 | Resus 2014;85:350

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20

RUSH

RUSH

Human Factors

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Quiet ECPR

Image from ep monthly

Time to CPR and Premorbid State

Matters

Time Coding doesn’t matter!

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A time to CHEER

Cookbook

Cardiac ArrestResuscitation

byResuscitationists

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