• Shyam Murali

ResusX 2019 Pearls from Day 2

With all new faculty and workshops, the second day of the #ResusX19 conference continued to explore important topics in critical care and emergency medicine. Here are your learning pearls from day two of the conference.


Hemorrhage Control with REBOA by Dr. Zaf Qasim

We hit the ground running on Day 2 of ResusX with a quick introduction to REBOA from Dr. Zaf Qasim, an EM Intensivist at the University of Pennsylvania.

  • REBOA = Resuscitative Endovascular Balloon Occlusion of the Aorta

  • Allows some degree of control before definitive care

  • Especially useful for noncompressible torso hemorrhage

  • While resuscitative thoracotomy is a REACTIVE procedure (done after the patient has lost pulses), REBOA is PROACTIVE to avoid periods of hypoxic insult

  • ER-REBOA catheter - Fits through a 7F sheath

  • Indications: exsanguination, refractory hypotension, witnessed arrest from hemorrhage

  • Contraindications: major bleeding above diaphragm, aortic injuries, pericardial tamponade

  • Options for catheter location: Zone 1 (above the diaphragm) and Zone 3 (between lowest renal artery to bifurcation). Avoid Zone 2 (between the diaphragm and renal arteries).

  • Rate-limiting step: Common Femoral Artery access. Place the line early; as shock state progresses, the artery will get smaller and more difficult to access

  • Evidence shows that REBOA is at least noninferior to cross-clamping the aorta. In the subgroups of prehospital arrest, in-hospital arrest, and profound hemorrhagic shock, REBOA significantly improves survival to discharge and may improve neuro intact survival.

  • Nontrauma applications: - pregnancy related complications: ruptured ectopic, postpartum hemorrhage - arterial GI bleeding - adjuct to medical cardiac arrest to augment central perfusion

  • Complications: AKI, limb amputations (reduced by using smaller introducer sheaths of 8F or smaller), multisystem organ failure, increased mortality

  • Duration of balloon inflation is extremely important; need to get to definitive control quickly.

  • Newer concept of partial REBOA is still being investigated

Dr. Qasim also hosted a REBOA insertion workshop for us:

Click the arrow to see more photos.

Fluid Resuscitation in Sepsis by Dr. Michael Winters

Check out my Surviving Sepsis Guidelines Summary to get the basics of sepsis care.

  • The optimal type, amount, and timing of fluids is still unclear in the data; needs to be individualized to the patient in front of you

  • Mechanisms of hypovolemia in sepsis: fluid loss (vomiting, diarrhea, sweating), vasodilatation, capillary leak leading to extravascular sequestration, peripheral pooling

  • Does getting fluids in the first hour actually change/improve outcomes? Low quality of evidence, optimal timing uncertain but earlier administration may decrease mortality.

  • What initial volume of fluids should we give? Low quality of evidence but initial bolus of 30mL/kg is probably okay for most patients, including those with CHF and ESRD - Interestingly, when you compare the EGDT to usual care (ProCESS, ARISE, ProMISe), fluid volumes administered are about equal: approximately 30mL/kg - Patients getting excessive fluids (>5L) may have worse outcomes

  • Balanced Crystalloids or Normal Saline in Critically Ill Adults? Balanced is better.

  • All evidence is still low quality, but give 30mL/kg of balanced crystalloids, sooner rather than later

The Crashing Asthmatic - Dr. Haney Mallemat

When in status asthmaticus, patients can take a breath in, but cannot breathe out. This leads to breath stacking. Here are some treatments for refractory asthma:

  • EPINEPHRINE: the "OB" (Original B-agonist) - In severe asthma, the airways are so tight that inhaled albuterol does not get to the distal airways - Need to give them something systemically first - Use anaphylaxis dose (0.3-0.5 IM)

  • HELIOX - Makes the gas less dense and easier to breathe - Marginal evidence for its benefits

  • KETAMINE - Tachypnea and agitation worsens breathing - Ketamine chills out the patient - Bronchodilation via different receptor

  • NONINVASIVE VENTILATION - Assists work of breathing - Increases time to fatigue

  • When should we intubate? - No lab test, no vital sign indications. Just clinical experience. - Probably time to intubate when the patient tires out, becomes somnolent, or has rising (or normalized) CO2 - Intubation should be performed by the most experienced intubator in the room - Go big with the tube (8.0 in female, 8.5 in male) - Slow gentle respirations, with plenty of exhalation time

  • Post-intubation medications - Take the patient deep - good analgesia first, then deep sedation - Propofol - also causes a helpful bronchodilation - Consider paralysis to improve ventilator synchrony

  • Setting up Vent - Volume control mode of vent > RR 10 > TV 7cc/kg > PEEP 3 (they have their own intrinsic PEEP) > Peak pressure alarm 60 > Flow rate 80 > Very LOW I:E ratio (ie. long expiration time)

  • VOLATILE ANESTHETICS can reverse bronchospasm

  • ECMO or ECCO2 (ECMO for CO2 clearance)

  • Permissive hypercarbia and acidosis (down to pH 7.1) is okay - Avoid "Euboxia"

  • Cardiac arrest: may likely be due to dynamic hyperinflation causing obstructive shock - Disconnect vent, look for a tube obstruction or pneumothorax - THEN start CPR

As a sidenote, here is my favorite ventilator troubleshooting mnemonic from Dr. Mallemat:


Wait, She's Pregnant? Optimizing ABC's for the Critically ill Obstetric Patient by Dr. Emily Damuth

  • Pregnancy --> Downregulation of cell-mediated immunity - WBCs don't work as well, allows mother to tolerate paternal/fetal antigens - More susceptible to encapsulated bacteria, viral pneumonia, etc.

  • There are many physiologic changes in pregnancy - FRC decreases by 20% - O2 consumption increases by 30% - Changes in chest volume - Minute ventilation increases by 40% - Increase in tidal volume, not rate - tachypnea is not physiologic, it is pathologic - Normal range of pH rises slightly to create appropriate gradient for gas transfer to fetus - Mother develops a compensatory metabolic acidosis (HCO3 is slightly lower than normal)

"Every obstetric airway should be considered a difficult intubation"
  • Changes in airway: increased oropharyngeal edema that worsens Mallampati classification, hyperemia can increase traumatic bleeding.

  • Lowered gastroesophageal sphincter tone, slower gastric emptying, increased abd pressure --> All lead to increased chance of regurgitation

  • Head-up position can increase FRC by 800mL, adding to safe apnea time - Ramped position also slows desaturation, decreases hypotension from IVC compression, and decreases regurgitation

  • Avoid severe alkalemia or acidemia Alkalemia - vasoconstriction of uterine arteries, decreasing blood flow to fetus

  • ARDS is 10x more common in pregnancy - increased hydrostatic pressure in face of reduced oncotic pressure

  • There is no good set of recommendations as pregnant patients are excluded from many studies - Need to extrapolate from data and expert opinion

  • Dr. Damuth recommends: - Lung protective - Permissive mild hypercapnea (pH>7.3) - PaO2 >70mmHg, SaO2 >95% - Pplateau </=30-35 - PEEP (increases FRC, prevents derecruitment, but can increase intrathoracic pressure and affect hemodynamics) - Adjuncts: APRV, paralysis, prone positioning, VV-ECMO for severe ARDS in pregnancy

5MinuteAirway by Dr. Terren Trott

Dr. Trott hosted an interactive session where he displayed some recorded intubation videos and asked an audience member to analyze what was going on. For each video he had a few learning pearls to improve our airway game:

  • Put lube on everything: laryngoscope, ET tube, even the stylet

  • Make sure you have a working IV for medications; if sedation or paralysis has not set in within an appropriate amount of time, check your IV and redose (more on that with Scott Weingart and EMRAP) - Consider IM dosing

  • The bougie is your best friend

  • If you can't get the coude tip through the vocal cords, try to use the back (straight) end of bougie

  • You can use the Macintosh blade in the same way you would use a Miller blade, but it may obscure your view

  • Utilize External Laryngeal Manipulation

  • Engage the hyoepiglottic ligament to flip the epiglottis out of the way

  • Take a midline approach if you are using a video laryngoscope; this will prevent angled views of the vocal cords that complicate passage of the tube

  • Vomit in the airway? Lead with suction, intentionally intubate the esophagus and inflate the cuff (then point the other end at the person you dislike most in the room)

  • Cardiac arrest? Consider placing an SGA instead until ROSC is achieved.

Catheter Based Management of Acute PE: Are we there yet? by Dr. Elias Iliadis

  • Unstable PE patients do not do well

  • PESI score can be helpful in determining what interventions we should employ

  • RV dysfunction and troponin elevation are associated with increased mortality

  • Various techniques exist to treat submassive and massive PE: - Percutaneous mechanical thrombectomy - Aspiration thrombectomy - Thrombus fragmentation - Rheolytic thrombectomy

  • Dr. Iliadis has been performing some incredible PE clot-busting procedures utilizing a new technology called EKOS - Ultrasound-facilitated, catheter-directed thrombolysis - ULTIMA Trial - EKOS vs heparin; proof of concept trial that showed the benefits of EKOS

Cooper criteria for using EKOS:

  • Immediate reduction in PA systolic pressures

  • Very low risk of bleeding

  • SHARED DECISION MAKING amongst various departments to roll out something like this

The Crashing Obese Patient by Dr. Michael Winters

  • Anatomic alterations: Excess neck fat, posteriorly displaced oral tissue, head will fall more posteriorly

  • Physiologic alterations: decreased pulmonary reserve (FRC), increased intraabdominal pressure, rapid hypoxemia

  • Maximize preoxygenation by sitting the patient up (decreases flow limitations, air trapping, and atelectasis

  • Preoxygenate with NIV - CPAP for 10 min at 10cmH2O; adds about 1 minute to safe apnea time

  • Intubate with ramped up bed (25-30 degrees)

  • Meds: In a recent study: 24% of patients get an inappropriate etomidate dose, 56% get an inappropriate succinylcholine dose. More likely to be underdosed.

  • Rapid Sequence Intubation: - Anticipate rapid desaturation - Preoxygenate sitting up - Intubate with ramped bed - Dose RSI meds appropriately

  • Ventilation: - 21.7% of ventilated obese patients are done so with injurious volumes - USE IDEAL BODY WEIGHT - RR 16-20 - PEEP 10-15 - Reverse Trendelenberg - displaces abdominal contents, patients will pull higher tidal volumes

Blocking the Septic Heart by Dr. Terren Trott

  • Beta blockade in sinus tachycardia in septic patients could decrease mortality by about 31.1%

  • Esmolol administration can result in: - Increased Stroke Volume - Reduction in troponins - Improved GFR - Reduction in total fluids administered - Stable right atrial pressures

  • Hypertrophic Cardiomyopathy has an intrinsic Left Ventricular Outflow Tract Obstruction (LVOTO) - Decreased cardiac output - Sabre-shaped doppler flow - Medical management = BETA BLOCKERS

  • 2015 study showed 22% of septic shock patients have evidence of LVOTO - "Pseudohypertrophy" - Mortality higher in septic patients with LVOTO (55% vs 33%)

  • Dr. Trott's protocol

Septic shock patient? --> fluid resuscitation with serial ultrasound. Refractory sinus tachycardia with LVOTO? --> Esmolol

Tracheostomy Emergencies by Dr. Emily Damuth

  • 40-50% of tracheostomy patients will have a complication

  • Dislodgement leads to about 1/2 of airway deaths

  • Anatomy of trache - Outer cannula - Inner cannula - Obturator (blunts insertion into the patient; outer cannula can damage the posterior wall) - Pilot balloon = cuff - Inner cannula is required for BVM

  • Need to know: - Size of inner diameter - Cuffed vs uncuffed - Reason for trache - Date of placement - stoma healing takes 7-10 days

  • 6 Step Algorithm for Troubleshooting

  • Trache stoma closes very quickly; most within 24hrs

  • Laryngectomy (3-5% of trache patients) - Cannot intubate from above - larynx is surgically connected to skin - "Obligate stomal breather" - Cannot be oxygenated through mouth or nose - You can oxygenate with pediatric BVM or a #3 or #4 LMA; reintubate via stoma as soon as possible

Demystifying the Resuscitative Thoracotomy by Dr. Zaf Qasim

Dr. Qasim's thoracotomy talk is perfectly summarized by his post on RebelEM.

  • HOTTT(T)

  • Use ultrasound first (FAST Exam) to help you decide whether you should perform resuscitative thoracotomy - check out this study by Inaba et al. that showed ultrasound to be highly sensitive and specific in prognosticating

  • If you are going to do a thoracotomy, do a clamshell - Open the chest - Deliver the heart - Repair the heart muscle lacerations - suture, staple, foley (with care) - Cross-clamp the aorta. You may need to break inferior pulmonary ligament. You can press the aorta up against spine to compress it if you cannot clamp it. - Use the hearty-starty machine to shock the heart out of V-fib if needed


Current Concepts and Controversies in Sepsis Resuscitation by Dr. Michael Winters

  • Antibiotics - Exact timing is still controversial, aim for within first 3 hours, no high quality studies

  • Pressor timing - Consider earlier administration - CENSER trial in Thailand showed that early low-dose norepinephrine improved shock resolution, had lower incidence of pulmonary edema and cardiogenic strain, and had no difference in other outcomes compared to standard care

  • Lactate - maybe does not need to be trended anymore(?) - ANDROMEDA-SHOCK compared peripheral perfusion strategy vs lactate strategy - Nonsignificant trend towards more favorable outcomes in peripheral perfusion strategy; also received slightly less IV fluids

Peripheral Vasopressors by Dr. Zaf Qassim

  • Delaying pressors in shock states can be detrimental

  • Central lines take time and carry risks

  • So just administer the vasopressors via peripheral IVs

  • Multiple studies show safety of peripheral pressors, even in sick patients

  • Majority of adverse events occur when IV was distal to antecubital fossa, or were administered for >4hrs

  • Consider the following variables:


The Low Flow LVAD by Dr. Colin McCloskey

  • LVADs are Preload Dependent and Afterload Sensitive

  • Centrifugal flow device that pumps blood from LV to Ascending Aorta

  • Only set variable is pump speed in RPM (eg. 5000RPM). Set to achieve a flow (eg. 4-6L) using a certain amount of Power (W)

  • Preload Dependent - Infections (especially driveline infections which frequently require explantation) are very common in LVAD patients --> distributive shock --> decreased venous return --> decreased LV filling --> decreased flows - Second most common complication = Bleeding (most often from GI bleeds). LVAD patients require systemic anticoagulations, vWF gets chewed up by rotor. > Judicious product use > Careful reversal of anticoagulation - RV failure will cause LV preload issues

  • Afterload Sensitive - Pump thrombosis (this is why LVAD patients require anticoagulation) > You'll see decreased flows but increased power > Signs/symptoms of hemolysis: hematuria, elevated LDH (>600 or 2.5x normal) - Elevated blood pressure > Number 1 cause of death in first 5 years of LVAD patients is hemorrhagic stroke. Use PCC for hemorrhagic stroke.

  • Crashing LVAD (no flow VAD): If no hum from VAD on auscultation --> initiate standard ACLS with compressions, defibrillation, everything

On a similar topic, check out Dr. William Krebs's lecture on the ED and Critical Care transport management of the Impella device.



This afternoon was again filled with some great workshops and skills stations. We covered fiberoptic awake intubations, critical care cases, ventilator alarm troubleshooting, advanced central venous access, and others. The final day of #ResusX19 is tomorrow; stay tuned for the last set of pearls for this year's conference!




Shyam Murali @smuramed

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