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://bi...
LMA in Cardiac Arrest    •   They didn’t buy it!    •   Used MRI to show LMA doesn’t impede flow!    •   Short paper respo...
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 & flui...
Ketamine or KetaMinhWho’s using it more because of Minh?
Ketamine or KetaMinh• What is it good for?  – Agitation/Aggression/Analgesia  – Procedural sedation  – Antidepressant  – H...
PCAs in the ED•   Review of 2 studies!•   Provide less-labor intensive analgesia•   Better pain scores•   Few more adverse...
Critical Care Palliation“When we can’t be aggressive with our  resuscitation – we need to be aggressive with  our palliati...
Critical Care Palliation3 things never to say:    1. “Do you want us to do everything?”    2. “Do you want us to resuscita...
Tranexamic AcidThe FOAMed world ask why we aren’t using it?  – Its cheap!  – Its an old drug!  – But it works!  – ?prehosp...
Pressure Poisoning• Lung protective ventilation – Meta Analysis• Not just in ARDS!• Lower tidal volumes = better outcomes
Pressure PoisoningStart 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•   Give ^60L/02/min•   Enable 100% 02, with 5/PEEP•   Humidified•   Great for NFI pts•   More comfortab...
PPI & Upper GI Bleeder!    • Face validity of using PPI’s    • 750 million per/yr USA    • Systematic R/V -Cochrane    • 2...
PPI & the Upper GI Bleeder!    No difference in:    • Mortality, rebleeding, need for surgery!http://thesgem.com/2012/12/s...
The Best Tricks of the Trade!
Difficulty feeding the NGT tube?• Try the SCANCRIT manoeuvre!                     http://www.scancrit.com/2012/05/30/scanc...
Opioid Induced Constipation =                            Naloxone                                                        =...
Superglue for CVCs• Need to secure that ART line or CVC during a  resus?Forget this:                   Try this:          ...
Need to Chemically Cardiovert SVT?
Combine Adenosine with the Flush•   Use 20ml syringe•   Draw up adenosine & flush together•   Administer by fast IV push• ...
Nebulised Naloxone    • Worried about acute withdrawal with IV      naloxone?    • Still got some respiratory effort?    •...
Stabilising Mandibular Fractures• Splinting mandibular dislocation/fracture                                • Easy as• Putt...
A Dose of Dex  • Casey been doing it for a while!  • Cochrane then decided to agree with him:  Benefits:  • Reduction of p...
Ruling & Managing the     RESUS ROOM
Life, Limb & Sight Saving                  Procedures• Published in emj & Resus.Me• Questions if we’re ready to perform:  ...
The Usual State of Readiness• Being ready to act with life-saving maneuvers• Managing your own catecholaminesBeing ready1....
The Usual State of Readiness1.Cognitively• Invisible simulation• Develop & prepare plans/scenarios in your   mind!• Knowin...
The Usual State of Readiness2. Materially• Equipment you need• When you need it• Where you need it• Checking your equipmen...
Mind of the Resuscitationist•   Being at the sharpest end of EM•   Making things happen•   Controlling your environment•  ...
Owning the Airway in 2012               Been dominated by:                 • From DL to VL           • To Human Factors & ...
The VortexChanging 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...
The FOAM Checklists
EMCrit Intubation
EM Updates Intubation Checklist
EMCrit Post-Intubation Package
EM Updates Asthma
In SummaryFOAMed in 2012 was all about:• Airway management/devices• Teaching us to use Checklist• How to Rule the Resus Ro...
Questions
Thank-youMay the FOAM be with you!
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Foam in review

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My FOAM in Review slides from SMACC2013, highlighting all the big hits from the EMCC podcasting and blogging world in 2012

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  • Unable to give credit or highlight them all but for more check out LITFL reviewThe big things that have changed practice
  • Both Andy and Jim didn’t buy the results of the study!
  • Over 10000 patients in this collarborative
  • Modified SIRS at triageSend lots of lactates- a high lactate means something you have do act on it Panic value of lactete of 4 or moreBroad spectrum Ab’s firstNot all need a central line
  • Excited delirium
  • Excited delirium
  • These have once been thought of the domain of the surgical ward
  • The ultimate ED critical care palliative care lecture by Ashley Shreves, when you cant be aggressive with resuscitation, be aggressive with your palliative care!
  • The ultimate ED critical care palliative care lecture by Ashley Shreves, when you cant be aggressive with resuscitation, be aggressive with your palliative care!
  • In the bleeding trauma patient!Its sad to say but We need a new patented drug for us the to start using it. 3 hour drug window, works best if given within 1st hour – better being given in prehospital environment
  • JAMA Article 2012 October Both featured on EMCRIT and ResusMeCheck Plateu pressures and titrate down
  • JAMA Article 2012 October Both featured on EMCRIT and ResusMeCheck Plateu pressures and titrate down
  • Allows patients to eat and drink, brilliant for the type 1 resp failures, pneumonia, smoke inhalation, burns ect
  • We know a lot of these patients bleed because of petic ulcers, makes sense to use a PPI
  • No evidence to support the routine use of these costly treatment in the emergency department.
  • Feeding NGT into the esophagus can sometime sometimes be hard, use the two finger technique. The two finger method works almost every time. When you feel the tube enter the nasopharynx on top of your fingertips, then use this to guide the tube down the esophagus
  • These patients often resistant to laxatives and enemas
  • The success of adensosine depends as much on the administration technique as it does the mechanism of action. While most drugs are metabolized in the liver, adenosine doesn’t even make it that far, being metabolised in the erythrocytes and vascular endothelial cells.Forget the stopcock, prevents fumbling, gets adenosine to the heart with seconds.
  • The flurry and excitement has been huge with some great post on how we manage and run the resus room.From great logistic strategies, being prepared and getting the most out of your staff in the resus room. The big 3 experts on this Cliff Reid, Rueben Strayer and Scott Weingart
  • Looks at training and procedual skilling for time critical interventions.
  • Knowing what you need to know Ie adrenaline in anaphylaxis, the rest you can look up
  • Don’t always rely on others check the equipment yourself
  • Human peursuaion getting the most out of your team and the people in the resus room.
  • Foam in review

    1. 1. FOAM in Review Kane Guthrie
    2. 2. FOAM from 2012• The review: – 189 different EMCC blogs & podcasts
    3. 3. Crowdsourcing
    4. 4. The Big FOAMed Hit’s Of 2012
    5. 5. The Popular OnesEMCrit DSI Best use of the Bougie
    6. 6. Thought Provokers& Game Changers!
    7. 7. LMA in Cardiac Arrest • Does the LMA decrease cerebral blood flow? • Using FOAMed to challenge the science!http://bit.ly/XGYcv9
    8. 8. 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
    9. 9. The Man who made Sepsis Sexy! NYC STOP Sepsis Collaborative
    10. 10. 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 effectivehttp://emcrit.org/severe-sepsis-resources/
    11. 11. Ketamine or KetaMinhWho’s using it more because of Minh?
    12. 12. Ketamine or KetaMinh• What is it good for? – Agitation/Aggression/Analgesia – Procedural sedation – Antidepressant – Hypotensive patients – Chronic pain – The DSI approach
    13. 13. 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!
    14. 14. 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/
    15. 15. Critical Care Palliation3 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/
    16. 16. Tranexamic AcidThe FOAMed world ask why we aren’t using it? – Its cheap! – Its an old drug! – But it works! – ?prehospital drug
    17. 17. Pressure Poisoning• Lung protective ventilation – Meta Analysis• Not just in ARDS!• Lower tidal volumes = better outcomes
    18. 18. Pressure PoisoningStart with:• 6-8ml/kg by IBW for all intubated ED patients And protect those lungs!
    19. 19. Hypoxic Patient?Needs lots of O2?Not for Intubation? What to do?
    20. 20. High Flow Nasal O2• Give ^60L/02/min• Enable 100% 02, with 5/PEEP• Humidified• Great for NFI pts• More comfortable NIV• Use for DSI! http://emupdates.com/2012/03/01/the-high-flow- nasal-cannula-in-the-emergency-department/
    21. 21. PPI & Upper GI Bleeder! • Face validity of using PPI’s • 750 million per/yr USA • Systematic R/V -Cochrane • 2000 Ptshttp://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/
    22. 22. 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/
    23. 23. The Best Tricks of the Trade!
    24. 24. Difficulty feeding the NGT tube?• Try the SCANCRIT manoeuvre! http://www.scancrit.com/2012/05/30/scancrit-manoeuvre/
    25. 25. 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/
    26. 26. Superglue for CVCs• Need to secure that ART line or CVC during a resus?Forget this: Try this: http://bit.ly/Sf1sXY
    27. 27. Need to Chemically Cardiovert SVT?
    28. 28. 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
    29. 29. 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/
    30. 30. 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
    31. 31. 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 Bactvs Viralhttp://broomedocs.com/2012/12/a-dose-of-dex/
    32. 32. Ruling & Managing the RESUS ROOM
    33. 33. Life, Limb & Sight Saving Procedures• Published in emj & Resus.Me• Questions if we’re ready to perform: – Time Critical InterventionsHighlights metacompetence:• Ability to apply the intervention @ the right time! http://resusme.em.extrememember.com/?p=6707
    34. 34. The Usual State of Readiness• Being ready to act with life-saving maneuvers• Managing your own catecholaminesBeing ready1. Cognitively2. Materially http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
    35. 35. The Usual State of Readiness1.Cognitively• Invisible simulation• Develop & prepare plans/scenarios in your mind!• Knowing what you need to know http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
    36. 36. The Usual State of Readiness2. Materially• Equipment you need• When you need it• Where you need it• Checking your equipment yourself! http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
    37. 37. 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
    38. 38. 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!
    39. 39. The VortexChanging the way we approach the difficult airway
    40. 40. 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.htm l
    41. 41. The FOAM Checklists
    42. 42. EMCrit Intubation
    43. 43. EM Updates Intubation Checklist
    44. 44. EMCrit Post-Intubation Package
    45. 45. EM Updates Asthma
    46. 46. In SummaryFOAMed 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!
    47. 47. Questions
    48. 48. Thank-youMay the FOAM be with you!
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