Quinn Cummings

In this episode I talked with Dr. Quinn Cummings (@resus_bae) about the topic of cognitive bias and some ways we can reduce the influence of biases in our practice. Quinn is an emergency physician with a special interest in this topic.During an average shift an emergency medical provider makes hundreds to thousands of decisions. To make these decisions, our brains use a combination of conscious and subconscious information. We tend to think that all our decisions are made objectively but, in fact, much of our decision making comes from knowledge or ideas that we are not even aware of. This is the concept of cognitive bias. A cognitive bias is a systematic error in thinking which can skew our ability to process information properly and accurately. This can lead to an improper diagnosis or treatment path for our patient. There are numerous examples of specific biases such as anchoring bias, confirmation bias, premature closure, etc. We discuss a few examples in the podcast but we encourage you to research more to see which ones you may be more susceptible to (see resources below).As always please feel free to share feedback, comments, or questions!Twitter: @amerelmanInstagram: @paramedicpractitionerFacebook: The Paramedic Practitioner PodcastEmail: amerelman@gmail.com  References and other resources:https://www.nuemblog.com/blog/cognitive-biashttps://first10em.com/cognitive-errors/  https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/ Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Med. August 2003, 1-6.Croskerry, P et al. Patient Safety in Emergency Medicine. Lippincott Williams &amp; Wilkins, 2009.Thomas, D. D., &amp; Mustafa, Y. Design for cognitive bias. Jeffrey Zeldman / A Book Apart. 2020.Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med 2003;41(1):110–120.Croskerry P. The feedback sanction. Acad Emerg Med. 2000 Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471.Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960.Abraham Kaplan (1964). The Conduct of Inquiry: Methodology for Behavioral Science. San Francisco: Chandler Publishing Co. p. 28. ISBN 9781412836296.Allison, Scott T; Messick, David M (1985). “The group attribution error”. Journal of Experimental Social Psychology. 21 (6): 563–579. doi:10.1016/0022-1031(85)90025-3Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Quality &amp; Safety 2016;25:808-820.Benau EM, Orloff NC, Janke EA, Serpell L, Timko CA. A systematic review of the effects of experimental fasting on cognition. Appetite. 2014 Jun;77:52-61. doi: 10.1016/j.appet.2014.02.014. Epub 2014 Feb 27. PMID: 24583414.Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: A meta-analytic review. Neurosci Biobehav Rev. 2017 Sep;80:586-604. doi: 10.1016/j.neubiorev.2017.07.010. Epub 2017 Jul 28. PMID: 28757454.O’Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. doi:10.4997/JRCPE.2018.306

In this episode I talked with Dr. Quinn Cummings (<a href="http://www.twitter.com/resus_bae" rel="nofollow" target="_blank">@resus_bae</a>) about the topic of cognitive bias and some ways we can reduce the influence of biases in our practice. Quinn is an emergency physician with a special interest in this topic.During an average shift an emergency medical provider makes hundreds to thousands of decisions. To make these decisions, our brains use a combination of conscious and subconscious information. We tend to think that all our decisions are made objectively but, in fact, much of our decision making comes from knowledge or ideas that we are not even aware of. This is the concept of cognitive bias. A cognitive bias is a systematic error in thinking which can skew our ability to process information properly and accurately. This can lead to an improper diagnosis or treatment path for our patient. There are numerous examples of specific biases such as anchoring bias, confirmation bias, premature closure, etc. We discuss a few examples in the podcast but we encourage you to research more to see which ones you may be more susceptible to (see resources below).As always please feel free to share feedback, comments, or questions!Twitter: <a href="http://www.twitter.com/amerelman" rel="nofollow" target="_blank">@amerelman</a>Instagram: <a href="https://www.instagram.com/paramedicpractitioner/" rel="nofollow" target="_blank">@paramedicpractitioner</a>Facebook: <a href="https://www.facebook.com/paramedicpractitioner" rel="nofollow" target="_blank">The Paramedic Practitioner Podcast</a>Email: <a href="mailto:amerelman@gmail.com">amerelman@gmail.com</a> References and other resources:<a href="https://www.nuemblog.com/blog/cognitive-bias" rel="nofollow" target="_blank">https://www.nuemblog.com/blog/cognitive-bias</a><a href="https://first10em.com/cognitive-errors/" rel="nofollow" target="_blank">https://first10em.com/cognitive-errors/</a> <a href="https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/" rel="nofollow" target="_blank">https://criticalcarenow.com/criticalcarecares-25-cognitive-biases-every-doctor-needs-to-know/</a> Croskerry, P. The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Academic Med. August 2003, 1-6.Croskerry, P et al. Patient Safety in Emergency Medicine. Lippincott Williams &amp; Wilkins, 2009.Thomas, D. D., &amp; Mustafa, Y. Design for cognitive bias. Jeffrey Zeldman / A Book Apart. 2020.Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med 2003;41(1):110–120.Croskerry P. The feedback sanction. Acad Emerg Med. 2000 Nov;7(11):1232-8. doi: 10.1111/j.1553-2712.2000.tb00468.x. PMID: 11073471.Caplan R.A., Posner K.L., Cheney F.W.: Effect of outcome on physician judgments of appropriateness of care. JAMA 1991; 265: pp. 1957-1960.Abraham Kaplan (1964). The Conduct of Inquiry: Methodology for Behavioral Science. San Francisco: Chandler Publishing Co. p. 28. ISBN 9781412836296.Allison, Scott T; Messick, David M (1985). “The group attribution error”. Journal of Experimental Social Psychology. 21 (6): 563–579. doi:10.1016/0022-1031(85)90025-3Lambe KA, O’Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Quality &amp; Safety 2016;25:808-820.Benau EM, Orloff NC, Janke EA, Serpell L, Timko CA. A systematic review of the effects of experimental fasting on cognition. Appetite. 2014 Jun;77:52-61. doi: 10.1016/j.appet.2014.02.014. Epub 2014 Feb 27. PMID: 24583414.Lowe CJ, Safati A, Hall PA. The neurocognitive consequences of sleep restriction: A meta-analytic review. Neurosci Biobehav Rev. 2017 Sep;80:586-604. doi: 10.1016/j.neubiorev.2017.07.010. Epub 2017 Jul 28. PMID: 28757454.O’Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225-232. <a href="https://pubmed.ncbi.nlm.nih.gov/30191910/" rel="nofollow" target="_blank">doi:10.4997/JRCPE.2018.306</a>

Our Brains Against Us: Cognitive Errors and Debiasing w/ Dr. Quinn Cummings

Reuben Strayer

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see. Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM.        A Law Enforcement Approach to ExDS    References and Resources Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient EMCrit 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer BCE 75 Reuben Strayer’s Agitated Patient emDocs Cases: ED Approach to Agitation https://www.nuemblog.com/blog/chemical-sedation  https://www.acepnow.com/article/droperidol-is-back-and-heres-what-you-need-to-know/ http://www.tamingthesru.com/blog/2019/4/20/the-return-of-droperidol https://havokjournal.com/fitness/medical/ketamine-it-may-not-be-a-solution-for-everything-but-its-not-at-fault-here/ Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): Redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006  Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000-1004. doi:10.1016/j.ajem.2017.02.026  Parsch CS, Boonstra A, Teubner D, Emmerton W, McKenny B, Ellis DY. Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study. EMA – Emerg Med Australas. 2017;29(3):291-296. doi:10.1111/1742-6723.12763 Miner JR. Ketamine is a good first-line option for severely agitated patients in the prehospital environment. Am J Emerg Med. 2018;36(3):501-502. doi:10.1016/j.ajem.2017.12.015 Michaud A. Restraint related deaths and excited delirium syndrome in Ontario (2004-2011). J Forensic Leg Med. 2016;41:30-35. doi:10.1016/j.jflm.2016.04.010 Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018;38(1):139-151. doi:10.1002/phar.2060   Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1. doi:10.1016/j.annemergmed.2015.11.028 Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. J Emerg Med. 2015;48(6):712-719. doi:10.1016/j.jemermed.2015.02.019 Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330 Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12(12):CD002830. Published 2016 Dec 15. doi:10.1002/14651858.CD002830.pub3 Lai PC, Huang YT. Evidence-based review and appraisal of the use of droperidol in the emergency department. Ci Ji Yi Xue Za Zhi. 2018;30(1):1-4. doi:10.4103/tcmj.tcmj_195_17 Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385. doi:10.1016/j.annemergmed.2018.04.027 Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749. doi:10.1197/j.aem.2003.06.015 Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8(Suppl 8):45-47. doi:10.1111/j.1528-1167.2011.03235.x Ramsay RE, Wilder BJ, Uthman BM, et al. Intramuscular fosphenytoin (Cerebyx®) in patients requiring a loading dose of phenytoin. Epilepsy Res. 1997;28(3):181-187. doi:10.1016/S0920-1211(97)00054-5 Hopkins U, Arias C. Large-volume IM injections: a review of best practices. Oncol Nurse Advis. 2013;4(february):32-37. Harrington L. Administer single-site 30-mL intramuscular injection? Medsurg Nurs. 2005;14(6):379-382. Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl alcohol swabbing before injection really necessary? Med J Aust. 2001;174(6):306. doi:10.5694/j.1326-5377.2001.tb143279.x Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger G. The safety of injecting insulin through clothing. Diabetes Care. 1997;20(3):244-247. doi:10.2337/diacare.20.3.244 Khawaja RA, Sikanda R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. J Liaquat Univ Med Heal Sci. 2013;12(2):109-114.

On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see. Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM. A Law Enforcement Approach to ExDS References and Resources <blockquote><a href="https://smacc.net.au/2016/09/disruption-danger-droperidol-emergency-management-agitated-patient/" rel="nofollow" target="_blank">Disruption, Danger, and Droperidol: Emergency Management of the Agitated Patient</a></blockquote> <blockquote><a href="https://emcrit.org/emcrit/dangerous-and-disruptive/" rel="nofollow" target="_blank">EMCrit 279 – The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer</a></blockquote> <blockquote><a href="https://emergencymedicinecases.com/reuben-strayer-agitated-patient/" rel="nofollow" target="_blank">BCE 75 Reuben Strayer’s Agitated Patient</a></blockquote> <blockquote><a href="http://www.emdocs.net/emdocs-cases-ed-approach-agitation/" rel="nofollow" target="_blank">emDocs Cases: ED Approach to Agitation</a></blockquote> <a href="https://www.nuemblog.com/blog/chemical-sedation" rel="nofollow" target="_blank">https://www.nuemblog.com/blog/chemical-sedation</a> <a href="https://www.acepnow.com/article/droperidol-is-back-and-heres-what-you-need-to-know/" rel="nofollow" target="_blank">https://www.acepnow.com/article/droperidol-is-back-and-heres-what-you-need-to-know/</a> <a href="http://www.tamingthesru.com/blog/2019/4/20/the-return-of-droperidol" rel="nofollow" target="_blank">http://www.tamingthesru.com/blog/2019/4/20/the-return-of-droperidol</a> <a href="https://havokjournal.com/fitness/medical/ketamine-it-may-not-be-a-solution-for-everything-but-its-not-at-fault-here/" rel="nofollow" target="_blank">https://havokjournal.com/fitness/medical/ketamine-it-may-not-be-a-solution-for-everything-but-its-not-at-fault-here/</a> Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): Redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006 Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000-1004. doi:10.1016/j.ajem.2017.02.026 Parsch CS, Boonstra A, Teubner D, Emmerton W, McKenny B, Ellis DY. Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study. EMA – Emerg Med Australas. 2017;29(3):291-296. doi:10.1111/1742-6723.12763 Miner JR. Ketamine is a good first-line option for severely agitated patients in the prehospital environment. Am J Emerg Med. 2018;36(3):501-502. doi:10.1016/j.ajem.2017.12.015 Michaud A. Restraint related deaths and excited delirium syndrome in Ontario (2004-2011). J Forensic Leg Med. 2016;41:30-35. doi:10.1016/j.jflm.2016.04.010 Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018;38(1):139-151. doi:10.1002/phar.2060 Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1. doi:10.1016/j.annemergmed.2015.11.028 Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. J Emerg Med. 2015;48(6):712-719. doi:10.1016/j.jemermed.2015.02.019 Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330 Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12(12):CD002830. Published 2016 Dec 15. doi:10.1002/14651858.CD002830.pub3 Lai PC, Huang YT. Evidence-based review and appraisal of the use of droperidol in the emergency department. Ci Ji Yi Xue Za Zhi. 2018;30(1):1-4. doi:10.4103/tcmj.tcmj_195_17 Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385. doi:10.1016/j.annemergmed.2018.04.027 Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749. doi:10.1197/j.aem.2003.06.015 Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8(Suppl 8):45-47. doi:10.1111/j.1528-1167.2011.03235.x Ramsay RE, Wilder BJ, Uthman BM, et al. Intramuscular fosphenytoin (Cerebyx®) in patients requiring a loading dose of phenytoin. Epilepsy Res. 1997;28(3):181-187. doi:10.1016/S0920-1211(97)00054-5 Hopkins U, Arias C. Large-volume IM injections: a review of best practices. Oncol Nurse Advis. 2013;4(february):32-37. Harrington L. Administer single-site 30-mL intramuscular injection? Medsurg Nurs. 2005;14(6):379-382. Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl alcohol swabbing before injection really necessary? Med J Aust. 2001;174(6):306. doi:10.5694/j.1326-5377.2001.tb143279.x Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger G. The safety of injecting insulin through clothing. Diabetes Care. 1997;20(3):244-247. doi:10.2337/diacare.20.3.244 Khawaja RA, Sikanda R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. J Liaquat Univ Med Heal Sci. 2013;12(2):109-114.

Agitation w/ Reuben Strayer

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.   Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman  Image: PulmCrit     References and Further Reading UpToDatehttps://emedicine.medscape.com/article/296301-overview https://canadiem.org/management-of-severe-asthma/ http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/ https://rebelem.com/rebelcast-crashing-asthmatic/ https://emcrit.org/ibcc/asthma/ https://asthma.net/treatment/prevention/ https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/ https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/ https://err.ersjournals.com/content/22/129/227.full https://www.ncbi.nlm.nih.gov/books/NBK430901/ https://www.ncbi.nlm.nih.gov/pubmed/11406055 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/ https://www.ncbi.nlm.nih.gov/pubmed/23235634 https://www.ncbi.nlm.nih.gov/pubmed/22479740 https://www.ncbi.nlm.nih.gov/pubmed/26033128 https://www.ncbi.nlm.nih.gov/pubmed/25447559 https://www.ncbi.nlm.nih.gov/pubmed/27289336 https://www.ncbi.nlm.nih.gov/pubmed/18922662 https://www.ncbi.nlm.nih.gov/pubmed/28754601 https://www.ncbi.nlm.nih.gov/pubmed/24865567 https://www.ncbi.nlm.nih.gov/pubmed/24731521 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management. Facebook: <a href="https://www.facebook.com/paramedicpractitioner/" rel="nofollow" target="_blank">https://www.facebook.com/paramedicpractitioner/</a> Instagram: <a href="https://www.instagram.com/paramedicpractitioner/" rel="nofollow" target="_blank">@paramedicpractitioner</a> Email: <a href="mailto:amerelman@gmail.com">amerelman@gmail.com</a> Twitter: <a href="https://twitter.com/amerelman" rel="nofollow" target="_blank">@amerelman</a> Image: PulmCrit References and Further Reading <a href="https://www.uptodate.com/contents/an-overview-of-asthma-management?search=asthma&amp;source=search_result&amp;selectedTitle=1~150&amp;usage_type=default&amp;display_rank=1" rel="nofollow" target="_blank">UpToDate</a><a href="https://emedicine.medscape.com/article/296301-overview" rel="nofollow" target="_blank">https://emedicine.medscape.com/article/296301-overview</a> <a href="https://canadiem.org/management-of-severe-asthma/" rel="nofollow" target="_blank">https://canadiem.org/management-of-severe-asthma/</a> <a href="http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/" rel="nofollow" target="_blank">http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/</a> <a href="https://rebelem.com/rebelcast-crashing-asthmatic/" rel="nofollow" target="_blank">https://rebelem.com/rebelcast-crashing-asthmatic/</a> <a href="https://emcrit.org/ibcc/asthma/" rel="nofollow" target="_blank">https://emcrit.org/ibcc/asthma/</a> <a href="https://asthma.net/treatment/prevention/" rel="nofollow" target="_blank">https://asthma.net/treatment/prevention/</a> <a href="https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/" rel="nofollow" target="_blank">https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/</a> <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x" rel="nofollow" target="_blank">https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/</a> <a href="https://err.ersjournals.com/content/22/129/227.full" rel="nofollow" target="_blank">https://err.ersjournals.com/content/22/129/227.full</a> <a href="https://www.ncbi.nlm.nih.gov/books/NBK430901/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK430901/</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/11406055" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/11406055</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23235634" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/23235634</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/22479740" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/22479740</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26033128" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/26033128</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/25447559" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/25447559</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/27289336" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/27289336</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/18922662" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/18922662</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/28754601" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/28754601</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24865567" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/24865567</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24731521" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/24731521</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/</a>

Altered Airways – A dive into asthma and COPD – Part II

 In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.  Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.  Facebook: https://www.facebook.com/paramedicpractitioner/ Instagram: @paramedicpractitioner Email: amerelman@gmail.com Twitter: @amerelman Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.                         Image: PulmCrit    References: References UpToDate https://emedicine.medscape.com/article/296301-overview https://canadiem.org/management-of-severe-asthma/ http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/ https://rebelem.com/rebelcast-crashing-asthmatic/ https://emcrit.org/ibcc/asthma/ https://asthma.net/treatment/prevention/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/ https://www.ncbi.nlm.nih.gov/books/NBK430901/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/ https://www.ncbi.nlm.nih.gov/pubmed/23235634 https://www.ncbi.nlm.nih.gov/pubmed/22479740

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share. Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists. Facebook: <a href="https://www.facebook.com/paramedicpractitioner/" rel="nofollow" target="_blank">https://www.facebook.com/paramedicpractitioner/</a> Instagram: <a href="https://www.instagram.com/paramedicpractitioner/" rel="nofollow" target="_blank">@paramedicpractitioner</a> Email: <a href="mailto:amerelman@gmail.com">amerelman@gmail.com</a> Twitter: <a href="https://twitter.com/amerelman" rel="nofollow" target="_blank">@amerelman</a> Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease. Image: PulmCrit References: References <a href="https://www.uptodate.com/contents/an-overview-of-asthma-management?search=asthma&amp;source=search_result&amp;selectedTitle=1~150&amp;usage_type=default&amp;display_rank=1" rel="nofollow" target="_blank">UpToDate</a> <a href="https://emedicine.medscape.com/article/296301-overview" rel="nofollow" target="_blank">https://emedicine.medscape.com/article/296301-overview</a> <a href="https://canadiem.org/management-of-severe-asthma/" rel="nofollow" target="_blank">https://canadiem.org/management-of-severe-asthma/</a> <a href="http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/" rel="nofollow" target="_blank">http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/</a> <a href="https://rebelem.com/rebelcast-crashing-asthmatic/" rel="nofollow" target="_blank">https://rebelem.com/rebelcast-crashing-asthmatic/</a> <a href="https://emcrit.org/ibcc/asthma/" rel="nofollow" target="_blank">https://emcrit.org/ibcc/asthma/</a> <a href="https://asthma.net/treatment/prevention/" rel="nofollow" target="_blank">https://asthma.net/treatment/prevention/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/</a> <a href="https://www.ncbi.nlm.nih.gov/books/NBK430901/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK430901/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/23235634" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/23235634</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/22479740" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/pubmed/22479740</a>

Altered Airways – A dive into asthma and COPD – Part I

http://www.cmaj.ca/content/188/17-18/E466    Mechanism of Slow-Fast AVNRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/    AVNRT versus AVRThttp:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/    Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRThttp:// https://litfl.com/sinus-tachycardia-ecg-library/    Atrial fibrillation with rapid ventricular response. Not the lack of visible P waves and irregularity that make the diagnosis.http:// https://litfl.com/atrial-fibrillation-ecg-library/    Atrial flutter with 2:1 conduction. Rate of 150 and fairly obvious flutter waves are present.    Atrial flutter with 2:1 conduction. Flutter waves are not overtly obvious, but the rate of 150 bpm helps suggest atrial flutter. Treatment with diltiazem will slow conduction and help reveal the flutter waves and treat the rate.    Atrial flutter with 1:1 conduction. The rate of 300 and regularity of QRS complexes helps confirm the diagnosis.http:// https://litfl.com/atrial-flutter-ecg-library/    AVNRT. A regular, narrow-complex tachycardia without obvious P-waves.http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/    AVRT in a patient with WPW. A regular, narrow-complex tachycardia without obvious P-waves.http:// https://litfl.com/pre-excitation-syndromes-ecg-library/    Junctional tachycardia. Retrograde P-waves are obvious before the QRS complexes but they are not always visible.http:// https://litfl.com/accelerated-junctional-rhythm-ajr/    Atrial fibrillation with WPW. Note the extremely rapid rate, 300 bpm at times, the wide QRS complexes and varying QRS morphologies. These features confirm the diagnosis.    Another example of atrial fibrillation with WPW. This is difficult to distinguish from polymorphic ventricular tachycardia.http:// https://litfl.com/pre-excitation-syndromes-ecg-library/     1. Patient sitting upright on stretcher2.  Patient blows into syringe for 15 seconds 3. At 15 seconds quickly lay patient supine and elevate the legshttp:// https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/  Reference: https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ https://litfl.com/pre-excitation-syndromes-ecg-library/ https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia.  Cochrane Database Syst Rev. 2017 Oct 12;10:CD005154. doi: 10.1002/14651858.CD005154.pub4.  Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M,  Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4.  Bibas L, Levi M, Essebag V. Diagnosis and management of supraventricular tachycardias. CMAJ. 2016;188(17-18):E466–E473. doi:10.1503/cmaj.160079 Hafeez Y, Armstrong TJ. Atrioventricular Nodal Reentry Tachycardia (AVNRT) [Updated 2019 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499936/

<a href="http://www.cmaj.ca/content/188/17-18/E466" rel="nofollow" target="_blank">http://www.cmaj.ca/content/188/17-18/E466</a> Mechanism of Slow-Fast AVNRT <a href="http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/</a> AVNRT versus AVRT <a href="http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/</a> Sinus tachycardia with P waves at the end of the T-wave. Theses can be less obvious and the EKG can be mistaken for AVNRT or AVRT <a href="http:// https://litfl.com/sinus-tachycardia-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/sinus-tachycardia-ecg-library/</a> Atrial fibrillation with rapid ventricular response. Not the lack of visible P waves and irregularity that make the diagnosis. <a href="http:// https://litfl.com/atrial-fibrillation-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/atrial-fibrillation-ecg-library/</a> Atrial flutter with 2:1 conduction. Rate of 150 and fairly obvious flutter waves are present. Atrial flutter with 2:1 conduction. Flutter waves are not overtly obvious, but the rate of 150 bpm helps suggest atrial flutter. Treatment with diltiazem will slow conduction and help reveal the flutter waves and treat the rate. Atrial flutter with 1:1 conduction. The rate of 300 and regularity of QRS complexes helps confirm the diagnosis. <a href="http:// https://litfl.com/atrial-flutter-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/atrial-flutter-ecg-library/</a> AVNRT. A regular, narrow-complex tachycardia without obvious P-waves. <a href="http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/supraventricular-tachycardia-svt-ecg-library/</a> AVRT in a patient with WPW. A regular, narrow-complex tachycardia without obvious P-waves. <a href="http:// https://litfl.com/pre-excitation-syndromes-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/pre-excitation-syndromes-ecg-library/</a> Junctional tachycardia. Retrograde P-waves are obvious before the QRS complexes but they are not always visible. <a href="http:// https://litfl.com/accelerated-junctional-rhythm-ajr/" rel="nofollow" target="_blank">http:// https://litfl.com/accelerated-junctional-rhythm-ajr/</a> Atrial fibrillation with WPW. Note the extremely rapid rate, 300 bpm at times, the wide QRS complexes and varying QRS morphologies. These features confirm the diagnosis. Another example of atrial fibrillation with WPW. This is difficult to distinguish from polymorphic ventricular tachycardia. <a href="http:// https://litfl.com/pre-excitation-syndromes-ecg-library/" rel="nofollow" target="_blank">http:// https://litfl.com/pre-excitation-syndromes-ecg-library/</a> 1. Patient sitting upright on stretcher 2. Patient blows into syringe for 15 seconds 3. At 15 seconds quickly lay patient supine and elevate the legs <a href="http:// https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ " rel="nofollow" target="_blank">http:// https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ </a> <h2>Reference:</h2> <ul><a href="https://litfl.com/supraventricular-tachycardia-svt-ecg-library/" rel="nofollow" target="_blank">https://litfl.com/supraventricular-tachycardia-svt-ecg-library/</a></ul> <ul><a href="https://litfl.com/pre-excitation-syndromes-ecg-library/" rel="nofollow" target="_blank">https://litfl.com/pre-excitation-syndromes-ecg-library/</a></ul> <ul><a href="https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/" rel="nofollow" target="_blank">https://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/</a></ul> <ul>Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. Cochrane Database Syst Rev. 2017 Oct 12;10:CD005154. doi: 10.1002/14651858.CD005154.pub4. </ul> <ul>Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4. </ul> <ul>Bibas L, Levi M, Essebag V. Diagnosis and management of supraventricular tachycardias. CMAJ. 2016;188(17-18):E466–E473. doi:10.1503/cmaj.160079</ul> <ul>Hafeez Y, Armstrong TJ. Atrioventricular Nodal Reentry Tachycardia (AVNRT) [Updated 2019 May 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: <a href="https://www.ncbi.nlm.nih.gov/books/NBK499936/" rel="nofollow" target="_blank">https://www.ncbi.nlm.nih.gov/books/NBK499936/</a></ul>

SVT is Not a Rhythm

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.   Airway Checklist ExamplesAnything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.comGrade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.Reference: EMCrit Checklist page SALAD Airway Rich Levitan on epiglottoscopy Video discussion proper steps of laryngoscopy (Credit: EMCrit) Video demonstrating the value of head elevation in grade 3a view (Credit: AIME Airway/EMCrit) Bougie and Positioning PART Trial Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044.     Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597.    Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184.    Feasibility of  upright patient positioning and intubation success rates At two academic EDs. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5.     Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):513-518. doi: 10.1007/s11739-016-1481-z. Epub 2016 Jun 14. Cricoid Pressure is Dead     Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.     Cricoid pressure: indications and complications. Landsman I. Paediatr Anaesth. 2004 Jan;14(1):43-7. Review.    Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy. Trethewy CE, Doherty SR, Burrows JM Clausen D. Acad Emerg Med. 2018 Jan;25(1):94-98. doi: 10.1111/acem.13326. Epub 2017 Nov 3.     Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting. Fenton PM, Reynolds F. Int J Obstet Anesth. 2009 Apr;18(2):106-10. doi: 10.1016/j.ijoa.2008.07.006. Epub 2009 Jan 13.     The Bougie and First-Pass Success in the Emergency Department. Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi: 10.1016/j.annemergmed.2017.04.033.   Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. 

This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful. <h2>Airway Checklist Examples</h2>Anything worse than grade 2a is ideally managed using a bougie. Image: <a href="http://nurse-anesthesia.com" rel="nofollow" target="_blank">nurse-anesthesia.com</a> Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized. <h2>Reference:</h2> <ul><a href="https://emcrit.org/emcrit/emcrit-intubation-checklist/" rel="nofollow" target="_blank">EMCrit Checklist page</a></ul> <ul><a href="https://emcrit.org/emcrit/having-a-vomit-salad-with-ducanto/" rel="nofollow" target="_blank">SALAD Airway</a></ul> <ul><a href="https://emcrit.org/emcrit/rich-levitan-airway-lecture/" rel="nofollow" target="_blank">Rich Levitan on epiglottoscopy</a></ul> <ul><a href="https://vimeo.com/17542057" rel="nofollow" target="_blank">Video discussion proper steps of laryngoscopy (Credit: EMCrit)</a></ul> <ul><a href="https://vimeo.com/117055694" rel="nofollow" target="_blank">Video demonstrating the value of head elevation in grade 3a view (Credit: AIME Airway/EMCrit)</a></ul> <ul><a href="https://emcrit.org/emcrit/bougie-and-positioning/" rel="nofollow" target="_blank">Bougie and Positioning </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/30167699" rel="nofollow" target="_blank">PART Trial Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/30167701" rel="nofollow" target="_blank">Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/26866753" rel="nofollow" target="_blank">Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/28202295" rel="nofollow" target="_blank">Feasibility of upright patient positioning and intubation success rates At two academic EDs. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/27300036" rel="nofollow" target="_blank">Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):513-518. doi: 10.1007/s11739-016-1481-z. Epub 2016 Jun 14. </a></ul> <ul><a href="https://first10em.com/birenbaum2018/" rel="nofollow" target="_blank">Cricoid Pressure is Dead </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/16713784" rel="nofollow" target="_blank">Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/14717873" rel="nofollow" target="_blank">Cricoid pressure: indications and complications. Landsman I. Paediatr Anaesth. 2004 Jan;14(1):43-7. Review. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/28960597" rel="nofollow" target="_blank">Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy. Trethewy CE, Doherty SR, Burrows JM Clausen D. Acad Emerg Med. 2018 Jan;25(1):94-98. doi: 10.1111/acem.13326. Epub 2017 Nov 3. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/19144507" rel="nofollow" target="_blank">Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting. Fenton PM, Reynolds F. Int J Obstet Anesth. 2009 Apr;18(2):106-10. doi: 10.1016/j.ijoa.2008.07.006. Epub 2009 Jan 13. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/28601269" rel="nofollow" target="_blank">The Bougie and First-Pass Success in the Emergency Department. Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi: 10.1016/j.annemergmed.2017.04.033. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/29800096" rel="nofollow" target="_blank">Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. </a></ul>

How We Make Easy Airways Hard – Part 2

This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful.  Ear-to-sternal-notch positioning Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE)The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency.Reference: A Modern Approach to Basic Airway Management Bougie and Positioning Simulation Scenario Resource DuCanto Suction Catheter Deep Survival Book Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):513-518. doi: 10.1007/s11739-016-1481-z. Epub 2016 Jun 14. Jesudian MC, Harrison RR, Keenan RL, Maull KI.Crit Care Med. 1985 Feb;13(2):122-3.  Davidovic L, LaCovey D, Pitetti RD.Ann Emerg Med. 2005 Jul;46(1):37-42.     

This is part 1 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving basic airway skills and avoiding common errors that make airway interventions less likely to be successful. Ear-to-sternal-notch positioning Patient sitting upright with ear-to-sternal notch positioning. Known as back up, head elevated (BUHE) The ideal mask seal using a BVM. The index and middle fingers pull the mandible forward maintaining airway patency. <h2>Reference:</h2> <ul><a href="https://www.jems.com/articles/print/volume-43/issue-4/features/a-modern-approach-to-basic-airway-management.html" rel="nofollow" target="_blank">A Modern Approach to Basic Airway Management</a></ul> <ul><a href="https://emcrit.org/emcrit/bougie-and-positioning/" rel="nofollow" target="_blank">Bougie and Positioning</a></ul> <ul><a href="https://emsimcases.com/" rel="nofollow" target="_blank">Simulation Scenario Resource</a></ul> <ul><a href="https://www.sscor.com/ducanto_catheter.html" rel="nofollow" target="_blank">DuCanto Suction Catheter</a></ul> <ul><a href="https://www.amazon.com/Deep-Survival-Who-Lives-Dies/dp/0393326152" rel="nofollow" target="_blank">Deep Survival Book</a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/26866753" rel="nofollow" target="_blank">Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/28202295" rel="nofollow" target="_blank">Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/27300036" rel="nofollow" target="_blank">Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):513-518. doi: 10.1007/s11739-016-1481-z. Epub 2016 Jun 14. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/3967502" rel="nofollow" target="_blank">Jesudian MC, Harrison RR, Keenan RL, Maull KI. Crit Care Med. 1985 Feb;13(2):122-3. </a></ul> <ul><a href="https://www.ncbi.nlm.nih.gov/pubmed/15988424" rel="nofollow" target="_blank">Davidovic L, LaCovey D, Pitetti RD. Ann Emerg Med. 2005 Jul;46(1):37-42. </a></ul>

How We Make Easy Airways Hard – Part 1

In this episode I discuss prehospital management oftraumatic cardiac arrest, broken into penetrating and blunt. In recent yearsthe pendulum has swung away from a nihilistic approach towards one thatmaximizes outcomes in the highest number of patients. This requires taking astandardized, aggressive approach when treating viable patients with traumatic arrest.In penetrating traumatic arrest, addressing reversible causes based on thelocation of the injury is essential. This primarily means hemorrhage controland volume restoration (ideally with blood products). It may also mean chestdecompression (ideally with finger thoracostomy) for treatment of pneumothoraxor hemothorax. In blunt arrest it is more difficult to determine anunderlying cause of arrest so a rehearsed, pre-planned “bundle” of caredirected at reversible causes should be delivered early. Chest compressionsshould not be expected to be effective until volume is restored or tensionphysiology is reversed. This approach is attributed by most people to Dr. John Hinds. Primary interventions include: Aggressive control of external hemorrhage.Maintenance of airway and ensuring oxygenation,ideally with intubationDecompression of both sides of the chest,ideally with finger thoracostomy but needle thoracostomy at minimumApplication of a pelvic binderReduction of all long bone fractures References Scott Weingart. EMCrit Podcast 135 – Trauma Thoughts with John Hinds. EMCrit Blog. Published on October 19, 2014. Accessed on May 24th 2019. Available at [https://emcrit.org/emcrit/trauma-thoughts-john-hinds/ ]. Traumatic cardiac arrest: a unique approach.Harris T, Masud S, Lamond A, Abu-Habsa M.Eur J Emerg Med. 2015 Apr;22(2):72-8. doi: 10.1097/MEJ.0000000000000180. Review. Konesky KL, Guo WA.Eur J Trauma Emerg Surg. 2018 Dec;44(6):903-908. doi: 10.1007/s00068-017-0875-6. Epub 2017 Nov 25. Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC.Resuscitation. 2018 Oct;131:48-54. doi: 10.1016/j.resuscitation.2018.07.032. Epub 2018 Jul 27. Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285–293. doi:10.1097/TA.0000000000001070

In this episode I discuss prehospital management of traumatic cardiac arrest, broken into penetrating and blunt. In recent years the pendulum has swung away from a nihilistic approach towards one that maximizes outcomes in the highest number of patients. This requires taking a standardized, aggressive approach when treating viable patients with traumatic arrest. In penetrating traumatic arrest, addressing reversible causes based on the location of the injury is essential. This primarily means hemorrhage control and volume restoration (ideally with blood products). It may also mean chest decompression (ideally with finger thoracostomy) for treatment of pneumothorax or hemothorax. In blunt arrest it is more difficult to determine an underlying cause of arrest so a rehearsed, pre-planned “bundle” of care directed at reversible causes should be delivered early. Chest compressions should not be expected to be effective until volume is restored or tension physiology is reversed. This approach is attributed by most people to <a href="https://litfl.com/john-hinds/" rel="nofollow" target="_blank">Dr. John Hinds</a>. Primary interventions include: <ol><li>Aggressive control of external hemorrhage.</li><li>Maintenance of airway and ensuring oxygenation, ideally with intubation</li><li>Decompression of both sides of the chest, ideally with finger thoracostomy but needle thoracostomy at minimum</li><li>Application of a pelvic binder</li><li>Reduction of all long bone fractures</li></ol> References <ul>Scott Weingart. EMCrit Podcast 135 – Trauma Thoughts with John Hinds. EMCrit Blog. Published on October 19, 2014. Accessed on May 24th 2019. Available at [<a href="https://emcrit.org/emcrit/trauma-thoughts-john-hinds/" rel="nofollow" target="_blank">https://emcrit.org/emcrit/trauma-thoughts-john-hinds/</a> ].</ul> <ul>Traumatic cardiac arrest: a unique approach. Harris T, Masud S, Lamond A, Abu-Habsa M. Eur J Emerg Med. 2015 Apr;22(2):72-8. doi: 10.1097/MEJ.0000000000000180. Review.</ul> <ul>Konesky KL, Guo WA. Eur J Trauma Emerg Surg. 2018 Dec;44(6):903-908. doi: 10.1007/s00068-017-0875-6. Epub 2017 Nov 25.</ul> <ul>Escutnaire J, Genin M, Babykina E, Dumont C, Javaudin F, Baert V, Mols P, Gräsner JT, Wiel E, Gueugniaud PY, Tazarourte K, Hubert H; on behalf GR-RéAC. Resuscitation. 2018 Oct;131:48-54. doi: 10.1016/j.resuscitation.2018.07.032. Epub 2018 Jul 27.</ul> <ul>Evans CC, Petersen A, Meier EN, et al. Prehospital traumatic cardiac arrest: Management and outcomes from the resuscitation outcomes consortium epistry-trauma and PROPHET registries. J Trauma Acute Care Surg. 2016;81(2):285–293. doi:10.1097/TA.0000000000001070</ul>

Traumatic Cardiac Arrest

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias.  References: http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia https://emcrit.org/ibcc/hyperkalemia/ Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033 Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3 Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15 (ECGs from Smith’s ECG Blog http://hqmeded-ecg.blogspot.com)     Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5      Hyperkalemia indicated primarily by peaked T-waves in V2-V4      Wide QRS and significantly peaked T-waves indicating hyperkalemia      Substantially widened QRS with sine wave morphology indicating severe hyperkalemia

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias. References: <ul><a href="http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia" rel="nofollow" target="_blank">http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia</a></ul> <ul><a href="https://emcrit.org/ibcc/hyperkalemia/" rel="nofollow" target="_blank">https://emcrit.org/ibcc/hyperkalemia/</a></ul> <ul>Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033</ul> <ul>Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3</ul> <ul>Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15</ul> (ECGs from Smith’s ECG Blog <a href="http://hqmeded-ecg.blogspot.com/" rel="nofollow" target="_blank">http://hqmeded-ecg.blogspot.com</a>) Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5 Hyperkalemia indicated primarily by peaked T-waves in V2-V4 Wide QRS and significantly peaked T-waves indicating hyperkalemia Substantially widened QRS with sine wave morphology indicating severe hyperkalemia

Hyperkalemia

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter. References Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710 Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004 Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23 Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10. Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/  IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter. References <ul>Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710</ul> <ul>Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004</ul> <ul>Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23</ul> <ul>Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.</ul> <ul>Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at <a href="https://emcrit.org/emcrit/scape/" rel="nofollow" target="_blank">https://emcrit.org/emcrit/scape/</a> </ul> <ul>IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM</ul> <ul>IMAGE 3 – Spiral of death in heart failure, Image from <a href="http://CrashingPatient.net" rel="nofollow" target="_blank">CrashingPatient.net</a></ul>

Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

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