armyemdoc
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Steve Schauer, DO, MS 👨🏻⚕️🚑 🪖| PGY15 | EM-tensivist | US Army | C2RASH Lab Director | (my opinions only, not medical advice)
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Listen to this termination of resuscitation… which is how it should happen. There are several things to note that Dr. Robby from The Pitt did here that are spot-on. 1. He, in no uncertain terms, told her parents that her cardiac arrest was non-survivable. This is not the time to list out percentages or probabilities. This is the time to provide certainty to the inevitable death. 2. He told the parents when the appropriate time was to terminate resuscitation. Notice… No one said, “hey, so, do you want us to keep going or what?”. When a statement like that or similar is used, what the family hear are, “so… do YOU want to let granny die now or what?” You, the medical professional, that understands physiology and abysmal outcome even if ROSC is achieved at this point should be the one bearing the burden of making that decision, not the family member. 3. He offered to allow the remaining family to come in before stopping all of the visible efforts of resuscitation. (see previous post on this topic) My general gist is something like this, “Johnny has had no pulse and no blood flow to the brain for 40 minutes. Even if all the things we are doing were to get his heart beating again, he has suffered permanent brain damage. He will never wake up and be the same person you’ve him as. Now is the appropriate time to stop.” More to come on potassium levels and cardiac arrest... #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #armyemdoc #resuscitation #research #data #family #death #cpr #medx #medtwitter
armyemdoc83,964 Aufrufe • vor 1 Jahr
Read the story 👇 It's so often that those of us who work in EM and critical care see devastating injuries and wonder whether we're really making a difference... SPC Jordan Kirkpatrick is a U.S. Army Soldier who was riding his motorcycle on his day off when he had a high-speed collision. He had a bad TBI (IPH, SAH, DAI), pulmonary contusions, multiple rib fractures, skull fracture, facial fractures, femur fracture, multiple pelvic fractures, and a splenic laceration. EMS found him hypotense with a GCS of 3. Shortly after EMS arrival, he arrested. EMS started CPR, an i-gel was placed, and his chest was decompressed with ROSC achieved. In the ED, they intubated him, placed chest tubes, and transfusions were started. He was emergently taken to the OR for a multi-surgeon case and received >30 units of blood. Shortly after surgery, he went into ARDS/TRALI refractory to all medical management. uchealth LifeLine air lifted in very critical condition to University of Colorado Anschutz where he was emergently cannulated for ECMO. He had a bolt and EVD placed, was deeply sedated, paralyzed, and cooled for his TBI. He spent several weeks on ECMO in our CTICU and then was decannulated and transferred to our STICU, where he spent several months receiving dozens of procedures. I was part of his critical team in the STICU for several weeks. He's now almost fully recovered mentally and is making progress physically recovering. Next week, he will be discharged from in-patient rehab. He will rejoin his fellow Soldiers at Fort Carson and transition to the Soldier Recovery Unit. The video and photos are from him and his family documenting his journey. It's patients like Jordan who remind you that what you do matters. (Photos, video, and story shared with patient and family permission) #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #trauma #motivation #motivating
armyemdoc35,260 Aufrufe • vor 1 Jahr
Can't intubate, can't ventilate - you've tried the bowling ball 🎳 technique, and an SGA won't seat (or their face is missing). You have to cric. Use the 4-step method the US military has perfected over the past 1.5 decades. 1. Knife 🔪 - 4+ cm incision of the neck (this is not the time to be dainty), 1cm incision of cric membrane 2. Finger - insert into new airway to hold position 3. Bougie - insert into trachea, will stop around 10cm 4. Tube - insert your tube over the bougie (Video from Rich Levitan -- FYI, I have no financial COIs other than DoD funding) #emergency #emergencymedicine #foam #foamed #foamcc #army #armymedicine #armyemdoc #tip #meded #trauma #icu #criticalcare #meded #airway #medic #combatmedic #military #navy #airforce #marines #prehospital #medx #medtwitter
armyemdoc51,593 Aufrufe • vor 2 Jahren
Are you using oral ketamine and midazolam for pediatric sedation? I've been doing this for years without much data. I'm glad to see more data coming out on this method. Their protocol: PO ketamine 6mg/kg, max 200 PO midaz 0.5mg/kg, max 15 This works great because it safely keeps the kid loopy for a while in the event you get pulled away for other urgent issues, particularly when it's a single-coverage ED. #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #data #research #science #medx #medtwitter
armyemdoc24,096 Aufrufe • vor 1 Jahr
What is the data on family presence during resuscitation/CPR? There’s been multiple RCTs performed on this topic with subsequent systematic review’s including a Cochrane review. One cluster RCT even included 1-year follow-up with family that were present during the resuscitation. Here’s the gist of what these studies demonstrate: -There appears to be no impact on patient mortality (IOW it does not degrade the quality of resuscitation) -Family members report lower PTSD, anxiety, and depression (this data is from prehospital setting) -Qualitative data suggests that it helps to ease into cessation of resuscitation -Several studies have highlighted the need for a dedicated team member to address the family during the resuscitation -One study assessing patient survivors found that 9 of them reported awareness of family presence without any negative effects -Assessments of staff members found no increased sense of stress My two cents is that there probably needs to be some preparation including notifying staff that the family will present so they are aware along with a dedicated staff member to prepare the family for what they are about to witness. #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #armyemdoc #resuscitation #research #data #ems #prehospital #ambulance #family #death #medx #medtwitter
armyemdoc21,768 Aufrufe • vor 1 Jahr
E-CPR is the use of ECMO in the setting of cardiac arrest, similar to what happened in this episode. In this episode a patient without reliable ROSC is emergently cannulated for veno-arterial-ECMO which provides cardiopulmonary support (veno-venous-ECMO is not useful for this indication for those not familiar with the devices). The data on this topic have found an inconsistent benefit in the short-term for improving survival with good neurological outcome. One SR-MA by Tommaso Scquizzato, MD found probable benefit for improving survival with good neurological outcomes when evaluating available RCTs, most notable with an initial shockable rhythm. However, a more recent SR-MA that included these RCTs along with observational data found no benefit. This suggests that the benefits, if present, are probably not as robust as we’d like, particularly when you consider the cost of an E-CPR program. There are several caveats about this data to be aware of… 1. The centers participating in the RCTs have very well-greased systems. These are not centers that dabble in E-CPR. This includes readily available proceduralists, intensivists that are familiar with VA-ECMO, perfusionists, ECMO nurses, RT’s that understand vent management while on ECMO, etc. One high-quality RCT found a median hospital arrival to successful cannulation time of 20 minutes – this is really fast for all the moving pieces involved (PMID: 36720132). Since these are clinical trials, they are also not subject to “indication creep” that invariably occurs when something becomes a routine practice. 2. There is a growing discussion about the applicability of the available data. Advancements in technology, particularly the microaxial flow pumps (e.g. Impella) have changed how we manage MCS, now commonly referred to as “Ecpella”. The Impella technology continues to advance with faster flow rates, right-sided support devices, and potentially future devices with oxygenators. #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #armyemdoc #resuscitation #research #data #heart #cpr #medx #medtwitter
armyemdoc19,336 Aufrufe • vor 1 Jahr
Orbital compartment syndrome is one of those rare events that many EM physicians may never have to intervene on in their careers. I was taught the lateral canthotomy and cantholysis technique that we see in this episode of The Pitt. However, another technique called the vertical lid split technique has been described, which is easier to do since it does not require blindly attempting to find the tendons to release. In this technique, the operator makes a 5mm incision vertically through the upper and lower lid along the lateral 1/3. This is technically easier since you can visualize the whole procedure, and as long as you properly elevate the lid, there is little risk of iatrogenic injury. We will likely never have an RCT to answer this question given the challenges with recruitment. Most of the current data is based on experiential data and cadaver studies. For more on this technique, check out the WikiEM page or th recent podcasts on the EMCrit Crew and EM:RAP #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #armyemdoc #resuscitation #research #data #eye #ouch #medx #medtwitter
armyemdoc15,247 Aufrufe • vor 1 Jahr
What is the data on pediatric drowning outcomes? A 2016 systematic review with meta-analysis included 24 studies and >3000 pediatric drownings. Here’s the gist of what they found: Factors associated with survival were: -Submersion time (longer=bad) -EMS response time (longer=bad) -Salt water versus fresh water (salt water improved survival) Things not associated with survival: -Age -Water temperature -Witnessed versus unwitnessed The most important point worth noting is that a submersion time >25 minutes was invariably fatal. This also highlights that if you stumble upon a pediatric drowning victim, your priorities should be extraction from the water and calling EMS. Another narrative review found the following: -If you are in deep water, two rescuer in-water resuscitation was associated with improved survival -1 small study assessed AED use on-board small boats and noted no adverse events -2 studies found that bystander CPR was associated with improved outcomes… duh -5 studies assessed discharge from the ED if they regain consciousness provided they have normal vital signs and a CXR w/o signs of pulmonary edema… of note, they all had brief submersion times -14 studies assessed ECMO (mostly VA), finding that it was most successful when used post-ROSC for refractory profound hypothermia with poor outcomes noted among E-CPR applications PMID: 27154004 PMID: 33549689 #emergency #emergencymedicine #criticalcare #icu #erlife #iculife #science #army #armymedicine #armyemdoc #resuscitation #research #data #family #death #cpr #pediatrics #kids #medx #medtwitter
armyemdoc10,862 Aufrufe • vor 1 Jahr
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