ResusX 2019 Pearls from Day 1
The three day ResusX conference is off to a great start with quick, high-yield lectures regarding resuscitation of a variety of patients. Here are your learning pearls from day one of conference.
Physiology-Guided CPR by Dr. David Gaieski
Dr. Gaieski kicked off the conference with one part of a two-part lecture focused on the targeting your therapy to the patient in front of you.
Whenever possible, make sure to resuscitate your dying or dead patients in a room designed for resuscitation
Dr. Gaieski went over a blood pressure-targeted approach to CPR that was shown to increase survival in this study - Swine model; asphyxia-associated VFib - Two groups: BP-targeted care (compression depth titrated to SBP 100, vasopressors titrated to CPP>20) or AHA-guided care (51mm compression depth, standard epi dosing) - Primary outcome: 24-hour survival - Higher survival and CPP in the BP care group - Number of vasopressor doses before first shock was higher in the BP-targeted group
He also addressed the "CPR Paradox," which seems to suggest that survival is higher for patients who undergo longer periods of CPR (Somebody please comment below if you know more about this concept; we would like to learn more about this and I don't think I have clearly explained it here)
MCPR can be used as a bridge to heart cath and stenting of stenotic vessels.
ECPR may be an important instrument in (some of) our toolboxes - significantly increased survival with good neurologic outcomes in multiple studies
Example of a Goal-Directed CPR Protocol from University of Michigan
Logistics of Hemodynamic Monitoring During Cardiac Arrest by Dr. Scott Weingart
Next up, Dr. Weingart spoke about how to actually set things up for hemodynamic monitoring.
Place an arterial line in the common femoral artery - Avoid the superficial femoral artery - Look with your ultrasound about 2-3cm below the inguinal ligament; scan up and down to identify where the SFA and DFA join to create the CFA - CFA cannulation is not only important for getting an accurate blood pressure, but also for the next steps that the patient might need (heart catheterization, REBOA, balloon pump, etc.)
Getting the Diastolic Blood Pressure - The numbers that your monitor will show you are the highest (SBP) and the lowest (DBP) blood pressures from your arterial line tracing -HOWEVER, the act of recoiling off the chest (with proper compressions) actually causes a falsely low DBP; sometimes this can even be a negative number
Waveform ETCO2 - Measures ventilation AND perfusion/circulation - Machine does not read this accurately either due to ongoing compressions - Look for the highest ETCO2 within each breath
Beyond ACLS: Epinephrine and Airway by Dr. Salim Rezaie
"ABC" paradigm has now switched to "CAB" - Emphasize high quality chest compressions with minimal to no interruptions and early defibrillation. These are the interventions that have consistently been shown to improve outcomes.
He referenced the PARAMEDIC2 and AIRWAYS2 trials and presented their outcomes
Dr. Rezaie's protocol for these two aspects of cardiac arrest management: - Airway (RebelEM post about AIRWAYS2 trial) > SGA > BVM > ETI - Epinephrine (RebelEM post about PARAMEDIC2 trial) > Start a dirty epi drip first (1mg code cart epi injected into a 1L bag) and just let it run > Titrate a second epi drip to target an arterial line waveform DBP>30mmHg (for coronary perfusion) and/or ETCO2>20mmHg > If you are not hitting the goal: FIRST optimize CPR, then adjust the drips > The epi infusions help avoid post-ROSC hypotension, improve cerebral and coronary perfusion pressures, and allow cognitive offloading
Check out my analysis of the existing research around airway management during cardiac arrest on EMDocs.net.
Ultrasound in Cardiac Arrest by Dr. Mae West
Only 45% of PEAs are really true PEAs; more than half the time, there is some cardiac activity on ultrasound
Half of the Hs&Ts can be ruled in or out with ultrasound
You can also identify fine VFib
A systematic review and meta-analysis showed high sensitivity, high specificity, and low negative likelihood ratio in predicting ROSC
The REASON Trial showed that cardiac activity on ultrasound was the variable most associated with survival following cardiac arrest
Downsides: - too much time can be spent doing ultrasound during a pulse/rhythm check (goal is <10 seconds) - views and images can be unclear and difficult to read
Consider TEE - Pros: facilitates image acquisition, decreases CPR interruptions, realtime CPR feedback, guides ECLS procedures - Cons: more invasive, more expensive, less accessible, smaller body of trained individuals
Resus Tonight with Rob and Allen
Nurse-led codes may be the way of the future
The nurse orchestrates standard ACLS protocols with his or her nursing team, while freeing up the physician to think and act beyond ACLS
Most important thing for this method to succeed is to have strong team trust
Laryngoscope as a Murder Weapon by Dr. Scott Weingart
When you make the decision to intubate, make sure to address your HOp killers early and continuously; plan ahead and respond aggressively to hypotension
Choose one of two paths for controlling hemodynamics: Protective vs Hemodynamically Neutral
RSI poses challenges because of intrinsic medication effects, loss of endogenous catecholamines, conversion of negative to positive pressure ventilation, and hypoventilation
Reduce the dose of your sedative. However, in HD unstable patients, etomidate dose must be raised to get adequate effects on the brain
Use ketamine instead as it is more HD stable; you will still need to use reduced doses
Hemodynamically protective strategy: Delayed Sequence Intubation - Sedative and paralytics are administered separately, allowing for extra time to improve oxygenation and/or hypotension - 0.25-0.5mg/kg IVP every 15-20 seconds until patient is dissociated; first pass absorption into the brain, so dissociation can be identified quickly - THEN use high dose paralytic: 2mg/kg of succinylcholine or rocuronium
Hemodynamically neutral strategy: Topicalized Awake Intubation - Suction the mouth and pad it dry - Topicalize with a lidocaine lollipop - tongue depressor with 5% viscous lidocaine - Nebulize with 4% lidocaine - Intubate with video laryngoscope or bronchoscope - Augment with small aliquots of ketamine 10mg - Use CPAP/Pressure Support mode on the ventilator to allow the patient to breath spontaneously
Debunking Collars and Backboard in Trauma by Dr. Salim Rezaie
Spinal immobilization does not immobilize
Spinal immobilization does not decrease spinal cord injury
Spinal immobilization worsens pulmonary function
Spinal immobilization worsens the physical exam (increases pain; 25% of healthy volunteers had midline spinal tenderness at 60 minutes of full spinal immobilization)
Spinal immobilization increases intracranial pressure
Spinal immobilization increases pressure ulcers (duration of immobilization is the highest predictor)
Spinal immobilization increases airway management difficulty
Use selective spinal immobilization and remove quickly
Have multidisciplinary grand rounds with your opponents to convince them of the real harms of spinal immobilization
Optimal Blood Pressure in Trauma by Dr. Salina Wydo
Use of fluid restrictive vs fluid liberal strategies vary widely
BP is extremely important to watch, trend, and treat in a trauma setting
Even a single BP drop (<105mmHg) is predictive of worse outcomes
Hypotensive resuscitation strategy reduces transfusion requirements and coagulopathy; however, we need more RCTs to further understand this
Dr. Wydo's practice - Stop the bleeding first - Replace what is lose; product liberal, crystalloid restrictive - MAP 50-55mmHg, SBP 90-100mmHg - Tailor your resuscitation to the patient in front of you
We Suck at Airway by Dr. Scott Weingart
Our practice environment and patients are extremely different from those of an anesthesiologist
He advocates for single technique mastery
"We need first-pass success in our patients."
We need DASH 1A - Definitive Airway Sans Hypotension on 1st Attempt
Dr. Weingart's Airway Algorithm (modified from Shock Trauma Airway Algorithm) 1. First pass: standard configuration (Mac/Miller) video laryngoscope + bougie first 2. Second pass: optimize what you did in first pass OR use hyperangulated video laryngoscope 3. Third pass: Attending only 4. SGA - must use ETCO2; oxygenate and denitrogenate (at least 3 minutes) then consider calling for help (anesthesia), performing a surgical cricothyroidotomy, or attempting intubation from above again 5. If all else fails, perform a surgical cricothyroidotomy
TXA for Everything That Bleeds by Dr. Salim Rezaie
This all encompassing table from RebelEM pretty much sums up his entire talk:
Logistics of Massive Transfusion Protocol by Dr. Scott Weingart
Massive Transfusion Protocol doesn't just mean obtaining the blood products and giving it; it includes the swift administration of those products (in Dr. Weingart's opinion, this means that each unit of product takes no more than one minute to infuse)
Obtain good vascular access - Peripheral IV 18ga or larger - Rapid Infusion Catheter (RIC) - Central access
Don't use "Bungholes" (ie. J-loop, extension set) - these just limit flow rates
Consider implementing a "Middle Ground Pack"; these can buy you time while you are assessing whether the patient will need lots more blood fast
Use a rapid infusion device: Level 1 Infuser, Belmont Infusion, etc. - Change the circuit after infusion of 10-12 units of product
Dr. Weingart's order of products: - Asynchronous administration of platelets and TXA - Alternate pRBC and Plasma 1:1 - Target MAP 65mmHg - If Fibrinogen is <150mg/dL, then administer a 10-pack of Cryoprecipitate - Significant calcium sequestration occurs with administration of platelets and plasma; give 1g CaCl for every 4 units of FFP
Consider TEG/ROTEM to identify what the patient needs at any given point in time
Garden Hose or Drinking Straw by Dr. Salina Wydo
No difference in outcomes between 28-32F chest tubes vs 36-40F chest tubes
A low quality study showed no difference in tube duration, rates of complications, and failure rates; however, there was a nonsignificant trend towards poorer outcomes
Dr. Wydo's opinions - Some hemothoraces and pneumothoraces can be managed without tubves - Pigtail catheters are fine for simple pneumothoraces - Penetrating trauma gets a surgical tube - Big air leaks with positive pressure ventilation gets a surgical tube - Failure of a pigtail catheter gets a surgical tube
The afternoon was jam-packed with some really excellent workshops and skills development: from chest tube insertion to ventilator management and ultrasound training to code choreography. We are looking forward to the next two days of this conference and the new things we will be learning!