Foam in review

FOAM in Review

Kane Guthrie

FOAM from 2012

• The review:– 189 different EMCC blogs & podcasts

Crowdsourcing

The Big FOAMed Hit’s

Of 2012

The Popular OnesEMCrit DSI Best use of the Bougie

Thought Provokers

& Game Changers!

LMA in Cardiac Arrest • Does the LMA decrease cerebral blood flow?

• Using FOAMed to challenge the science!

http://bit.ly/XGYcv9

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

The Man who made Sepsis Sexy!

NYC STOP Sepsis Collaborative

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/

Ketamine or KetaMinh

Who’s using it more because of Minh?

Ketamine or KetaMinh• What is it good for?– Agitation/Aggression/Analgesia– Procedural sedation – Antidepressant– Hypotensive patients– Chronic pain – The DSI approach

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!

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/

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/

Tranexamic Acid

The FOAMed world ask why we aren’t using it?

– Its cheap! – Its an old drug!– But it works!– ?prehospital drug

Pressure Poisoning

• Lung protective ventilation – Meta Analysis• Not just in ARDS!• Lower tidal volumes = better outcomes

Pressure Poisoning

Start with:• 6-8ml/kg by IBW for all intubated ED patients

And protect those lungs!

Hypoxic Patient?

Needs lots of O2?

Not for Intubation?

What to do?

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!

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/

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/

The Best Tricks of the Trade!

Difficulty feeding the NGT tube?

• Try the SCANCRIT manoeuvre!

http://www.scancrit.com/2012/05/30/scancrit-manoeuvre/

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/

=

Superglue for CVCs• Need to secure that ART line or CVC during a

resus?Forget this: Try this:

http://bit.ly/Sf1sXY

Need to Chemically Cardiovert SVT?

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

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/

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

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/

Ruling & Managing the

RESUS ROOM

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

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/


1.Cognitively• Invisible simulation • Develop & prepare plans/scenarios in your

mind!• Knowing what you need to know



2. Materially • Equipment you need• When you need it• Where you need it

• Checking your equipment yourself!


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

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!

The Vortex

Changing the way we approach the difficult airway

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

The FOAM Checklists

EMCrit Intubation

EM Updates Intubation Checklist

EMCrit Post-Intubation Package

EM Updates Asthma

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!

Questions

Thank-you

May the FOAM be with you!

Health & Medicine

Foam in review