Welcome to the sensational 76th edition!
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.
The Most Fair Dinkum Ripper Beaut of the Week
Cliff reviews 3 game changing papers over the past week, and takes out top spot in the review as a result:
- You have a patient in cardiac arrest who has had excellent resuscitation from the point of collapse, and who has treatable underlying pathology (eg. PE or STEMI). However you’re unable to get return of spontaneous circulation… so you call it. Someone just died for whom the technology exists to save them. Can’t say it any better than that Cliff! For more, read: Extracorporeal cardiopulmonary resuscitation. ECLS the future ACLS!
- Superglue for CVCs - No more faffing around suturing in these big lines during resuscitation, just glue em!
- Hypothermia after long down times. Take home point: Cooling the patient is more likely to make a difference in the ‘long down time’ patient, even though the overall survival in that group is obviously less.
The LITFL Review Top Picks
- Spinal injury sequelae - Casey digs deep into the literature to answer some questions on managing the critically injured spinal patient, and comes up with a post on where the evidence is at, and what is current best practice.
- FOAM Party! (The Future of Medical Education). Amazing post by Lauren on how to embrace FOAM and maximise your learning benefits.
- Why we think the LMA is probably safe in cardiac arrest – Andy and Jim take on a recent study to show that the LMA is an excellent device for managing the airway in cardiac arrest.
- How would you react? - A tough situation to be in, but check out the comments at the bottom for some sound advice or share your own advice.
- Over the counter Naloxone - A point and counterpoint debate on this often tricky topic…Is the benefit better that the harm?
Academic Life in Emergency Medicine
- Mini-guide to Twitter: Why should I join? - The advantages far outweigh the disadvantages: you get to engage, learn and disseminate information quickly, easily and effectively. Great summary on this awesome social media resource by Javier!
- Trick of the Trade: Calcium gel for hydrofluoric acid burns- nice summary on the tips and tricks for managing this tricky presentation.
- Three hospitals in parallel dimensions – An inspiring but hard hitting piece of writing by Domhnall on the real hospital and the specialty of emergency medicine. A must read!
- Initial Treatment of Acute Deep Venous Thrombosis (DVT) of the Leg (ACCP/Chest Guidelines) — Interesting pearl: Most people with symptomatic DVT also have PE (either symptomatic or “silent”).
- Which patient has a better blood pressure, the patient with a blood pressure of 110/40 or the patient with a blood pressure of 90/60?
- Mean arterial pressure (MAP) is generally considered to be the organ perfusion pressure in an individual. Because MAP requires an inconvenient calculation, we’ve all been taught…misled perhaps…into focusing on systolic blood pressure (SBP) as a marker of how well-perfused a patient is, and we tend to ignore the diastolic blood pressure (DBP).
- It’s important to remember, however, that we spend most of our lives in diastole, not systole. As a result, our organs spend more time being perfused during diastole than systole. The MAP takes this into account: MAP = (SBP + DBP + DBP)/3. DBP is more important than SBP!
- So which patient is perfusing his vital organs better, the one with a BP of 110/40 or the one with a BP of 90/60? Do the MAP calculation…90/60 is better than 110/40!
- Pay more attention to those diastolic BPs!
- Neonatal Seizures – Not a Benzo Deficiency!. Look for the cause not the treatment in the seizing neonate!
- Natalie poses the question and reviews the literature on whether we should now be moving away from ketamine into the dark, mysterious and historical world of etomidate for paediatric sedation? Let’s find out..! In If it ain’t broke…
- 4 brilliant minds of FOAM sit down and discuss Haemorrhagic shock in remote settings. What to do when resources are poor and patient is bleeding out. Great podcast dudes and dude-ess.
- Amit provides us with a bit more on this topic on his own blog. Check out Early Fluid Resuscitation in Severe Trauma.
- Conservatism Fails. The conservative approach didn’t work in this case… But doesn’t mean it will fail in other cases. Bottom line we need some good studies/evidence in this area.
- Aaron Sams’ Flipped Classroom - Another exciting, different but effective approach to teaching in the classroom.
- If you have nothing booked to do in November… Baltimore is the place to be. The Course is Coming!
- 5 Things Presenters Need To Know - a must watch for all educators and presenters.
- Not-So Routine Surgery on Dabigatran - this case does highlights the amazing difficulties we face when trying to reverse and stabilise patients on this drug.
- Prehospital Ventricular Fibrillation in a Young Woman. What is the Diagnosis? Can you pick the electrolyte that caused this?
- The higher … the better! Is it time that we aim for saturation’s of 96-98% in all our critically ill patients. Be interested to see more FOAM review’s on this study.
- 6 easy steps on Becoming a Team Leader the right way!
- The Severe Asthmatic: Intubation, Mechanical Ventilation, and Complications - Short sharp review on the recent literature on managing the tubed asthmatic. Its not as easy as some might think!
- The Emergency Airway: Three Phases of Airway Management: Machiavellian, Renaissance, and Enlightenment.
Keeping Up With Emergency Medicine
- Lactate Increments For Sepsis Patients – Bottom line: septic patients with increasing lactate have increased mortality and need more aggressive resuscitation.
- Seth provides us with his thoughts on (Landmark vs US) vs (DL vs VL), following a recent G+ hangout with some of the great FOAM minds around.
- How long is long enough for hospital resuscitation? This study suggest we maybe a bit premature in calling time of death in-hospital cardiac arrest patients.
The LITFL Review Shout Out of the Week
Shout of the week goes to…..Emergency Medicine Education a relatively new blog by Kent Robinson (@drkentrobinson). Emergency Medicine Education is about is an open medical resource for those with a special interest in Emergency Medicine, and also targets those with a special interest in emergency medicine education.
See some of Kent’s recent post:
- Crash-2 – “The Original” and CRASH-2 “The 2012 Update”
- Aortic Balloon Counterpulsation – “not all it’s cracked up to be”
- Gastrointestinal Bleeding – Probe Volume 15, Issue 27.
- Systolic BP < 105 indicative of significant injury in trauma.
News from the Fastlane
Its been a MASSIVE week on LITFL:
- Firstly some off the LITFL team have teamed up to create what looks to be the greatest ever critical acre and emergency medicine conference! Don’t believe me then check out SMACC DownUnder!
- John Larkin pipes back in with a post on Trauma! Major Burns. Nice work John!
- On the FOAM front Mike tells us Why The #FOAMed Hashtag?, and What is driving the #FOAMed revolution?. Whilst Chris commissions some artwork that portrays the man with FOAM at the mouth in Need Hope? Get FOAMed!
The Final Words
- “CPR in pure traumatic arrest, useless. Crack it, or call it.”
— Scott Weingart
- ”If you don’t recognize the rhythm, shock it until you do.”
— via Joe Lex (Unknown Source)
That’s it for now…
Hopefully this roundup of the world of electronic emergency medicine and critical care education for everyone helps you to deal with anyone, anything, anywhere at anytime for at least another week! If you’d like to suggest something for inclusion in the next edition of The LITFL Review, email kane AT lifeinthefastlane.com
LITFL Review EM/CC Educational Social Media Round Up
Emergency Medicine and Critical Care Blogroll
Emergency Medicine and Critical Care Podcasts
123Sonography.com — Academic Life in Emergency Medicine — Adventure Medicine— A Life at Risk — All LA Conference — Al Sacchetti’s Youtube — Bedside Ultrasound — Better in Emergency Medicine — Broome Docs — CCM-L.org — CLIC-EM — Critical Care Perspectives in EM — Dave on Airways —DrGDH — Dr Smith’s ECG Blog — ECG Academy — ECG Guru — ECG of the Week—ED Exam — EDTCC — EKG Videos — EM Basic — EM Core Content — EMCrit — Emergency Medical Abstracts —EMERJENCYWEBB –EmergencyLondon — Emergency Medicine Cases — Emergency Medicine Education — Emergency Medicine News — Emergency Medicine Ireland — Emergency Medicine Tutorials—Emergency Medicine Updates —Emergucate —EM Literature of Note — empem.org — EMpills — Emergency Physicians Monthly — EM Lyceum — EMProcedures — EMRAP — EMRAP: Educators’ Edition — EMRAP.TV — EM REMS — ER CAST — Free Emergency Medicine Talks — GMEP — Gmergency! — Greater Sydney Area HEMS — HQmeded.com — ICU Rounds — Impactednurse — Intensive Care Network —iTeachEM - keepcaring — Keeping Up With Emergency Medicine — KeeWeeDoc — KI Docs — LipheLongLurnERdok — MDaware — MD+ CALC — MedEDMasters — Medical Education Videos — Medicina d’urgenza — Medicine for the Outdoors — Micrognome — Movin’ Meat — Neurointensive Care — Pediatric EM Morsels — PEM ED — PEMLit — PHARM — Practical Evidence — Priceless Electrical Activity — Procedurettes — PulmCCM.org — Radiology Signs — Radiopaedia — Resus.com.au — Resus.ME — RESUS Room — Richard Winters’ Physician Leadership —ruralflyingdoc — SCANCRIT — SCCM Blogs — SCCM Podcast — SEMEP — SinaiEM — SinaiEM Ultrasound — SMART EM — SonoSpot — StEmylns — Takeokun — thebluntdissection—The Central Line — The Ember Project —The Emergency Medicine Resident Blog — The NNT — The Poison Review — The Sharp End — The Short Coat —The Skeptics Guide to Emergency Medicine — The Sono Cave - The Trauma Professional’s Blog — underneathEM.com — ToxTalk — TJdogma — Twin Cities Toxicology — Ultrarounds — UMEM Educational Pearls — Ultrasound Village
About Kane Guthrie
One comment on the UMEM Educational Pearls regarding blood pressure.
The automated non-invasive BP systems (NIBP) use the principle of oscillometry to measure blood pressure. In plain English, this means that the automated NIBP actually are measuring the MAP, and deriving the Systolic and Diastolic numbers from a formula within the monitor. If the blood pressure is worrying you, you’ll have to go back to Kortokoff sounds (measuring the BP manually), or go invasive.
Oscillometry works by occluding blood flow, then sensing the subtle perturbations in cuff tension that occur with steady and slow cuff release. You can use oscillometry with a hand held manometer too--just look for the “wiggles” in the gauge needle as the cuff is released. Now you are using oscillometry too! A quick and easy way to get a ball-park BP reading when you can’t use a stethoscope, can’t find a stethoscope, or you’re in an aircraft when you can’t hear a stethoscope. For G_d’s sake, I don’t even carry a stethoscope anymore.
With respect to NIBP. The big question is how is the MAP defined and measured? MAP has previously been defined by SBP, DBP and HR. It has never been defined as a “measured” value. It has always been calculated from SBP, DBP and HR and the standard formula depends on the HR being about 66? So I’m not sure how to interpret the MAP as presented by NIBP. Anyone know how this works
Mike
Mike, the answer to this may actually be more related to the specific make/model/brand of monitor. The Medical Electronics/Biomed Engineer in your hospital can find this out, or you can call the technical support people at the manufacturer to find out. Oscillometry devices directly measure MAP, but the number they display, ironically, can in some cases be calculated from the Sys/Dias (which doesn’t make sense in a way, since the Sys/Dias is calculated in these devices anyway). Here’s an NEJM article link on that topic:
http://www.njmonline.nl/getpdf.php?id=10000394
I fail to see any use for that study of SpO2 values. Of course I only have access to the abstract, but it sounds like all they found was an association between lower saturations and higher mortality. I’d be more interested if they hadn’t found one.
Based on the abstract, study in no way speaks to whether actually administering oxygen and increasing an SpO2 of 95% to 98% would improve outcomes. I highly doubt it would, so I can’t imagine why they would try to suggest changing the target values for treatment. If they wanted to offer any kind of honest conclusion, it would be that having an oxygen saturation of 95% on room air puts you into a slightly higher risk range than if it was 97%. I’m still not sure how that would change anything, because it’s not like you’re going to admit every patient with pneumonia an a room-air sat of 95%. You’d probably kill more with hospital-acquired complications before you saw a narrowing of that 2% difference in absolute mortality.