just the pearls 2014 acep - emcrit project · 11/1/2014 1 everything i do is off-label! just the...
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11/1/2014
1
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
3
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
8
FingerThoracostomy
200 ml Blood on LNothing on R
CT on Left
ChestIntra-P
Retro-PThighStreet
FASTLiver Tip
with Patient inTrendelenberg
11/1/2014
9
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
10
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
11/1/2014
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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
11/1/2014
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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
20
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
11/1/2014
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Max Harry Weil
Disease-a-Month 1997
Airway
Convert to Tube ASAP
11/1/2014
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Custom Bent Bonfils Fiberoptic Stylet
Breathing
GrossmanOn Combat
Hook them to the Ventilator
11/1/2014
25
Set Peak Pressure Limit to > 100 cm
H20
Set therate low
Circulation QualityCompressions
What about depth?
11/1/2014
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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
11/1/2014
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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
11/1/2014
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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
11/1/2014
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20
RUSH
RUSH
Human Factors
11/1/2014
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Quiet ECPR
Image from ep monthly
Time to CPR and Premorbid State
Matters
Time Coding doesn’t matter!
11/1/2014
31
A time to CHEER
Cookbook
Cardiac ArrestResuscitation
byResuscitationists
11/1/2014
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