LITFL • Life in the Fast Lane Medical Blog https://lifeinthefastlane.com Emergency medicine and critical care medical education blog Fri, 08 Jun 2018 02:23:05 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.6 https://i0.wp.com/lifeinthefastlane.com/wp-content/uploads/2017/03/LITFL_LOGO_Transparent_001.png?fit=32%2C32&ssl=1 LITFL • Life in the Fast Lane Medical Blog https://lifeinthefastlane.com 32 32 56961984 Medmastery: Acute Respiratory Distress Syndrome (ARDS) https://lifeinthefastlane.com/medmastery-ards/ https://lifeinthefastlane.com/medmastery-ards/#respond Wed, 06 Jun 2018 10:20:53 +0000 https://lifeinthefastlane.com/?p=177282 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

We explore the most common oxygenation and ventilation complications associated with ARDS in this video from Medmastery's Mechanical Ventilation course.

Medmastery: Acute Respiratory Distress Syndrome (ARDS) sabrine

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

The team at Medmastery are providing LITFL readers with a series of FOAMed courses from across their website.

Looking at acute respiratory distress syndrome today with a video from the Mechanical Ventilation Essentials course exploring the most common oxygenation and ventilation complications associated with ARDS.

Further reading:

Guest post: Josh Cosa, MA, RRT-ACCS, RRT-NPS, RCP. Registered respiratory therapist and respiratory care practitioner, Clinical Education Manager at Philips.

I received my license to practice in 2003 and I have been teaching, managing, monitoring, and modifying ventilator settings ever since. I live in Southern California and have learned from and worked with some of the best teachers anyone could meet.” –Josh Cosa

Medmastery: Acute Respiratory Distress Syndrome (ARDS) sabrine

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How to Read an ECG https://lifeinthefastlane.com/how-to-read-an-ecg/ https://lifeinthefastlane.com/how-to-read-an-ecg/#respond Tue, 05 Jun 2018 01:51:30 +0000 https://lifeinthefastlane.com/?p=177577 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Interpreting ECG’s is trickier than you think. One must have a system, preferably one that will stand up to the pummel of ED situations and environmental influences: time pressures, incomplete information, typhoons, that sort of thing.

How to Read an ECG Michelle Johnston

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Interpreting ECG’s is trickier than you think. One must have a system, preferably one that will stand up to the pummel of ED situations and environmental influences: time pressures, incomplete information, typhoons, that sort of thing.

The technique I employ has been honed over years of having a handful of seconds to come up with a germane and reasonably firmish electrocardiographic diagnosis. Mostly ECGs can be read by skidding; skimming the page with one of the currently unused quadrants of your vision (a kind of reverse homonymous quadrantinopia). This double-jointed vision is very useful for an Emergency Physician, and allows the remaining three free to scan 1) the patient, 2) the intern trying to cannulate a flailing arm in the next bed, 3) the ruckus swarming around a trolley being wheeled in from the ambulance bay, and 4) the monitor squealing the Very Important Alarm across the corridor. Realising that these don’t add up you discover you have not been looking at the ECG at all, and return to it, asking ‘so what did the patient come in with?’

Once you establish that the patient does not have VF or asystole, both of which are suboptimal to see on a 12 lead, you are free to enjoy the puzzle of ECG Interpretation. Mostly people rely on either Type 1 (heuristics, rule of thumb, pattern recognition – the chicken sexing sort) thinking, or Type 2 thinking, which involves the laborious but ultimately rewarding system of trawling through each element of the ECG (rate, rhythm, axis, intervals, ST’s yada yada). I recommend the use of Type 3 thinking* which involves a combination of panic (usually about something else, such as you not remembering the important piece of information imparted to you by a nurse which requires acting on Right Now), visual memory of the thousands of ECGs which have been flashed in front of you during your career, cross-referencing the ECG with the clinical vignette provided, obscure fascination with the history of ECGs leading to an unwavering joy that these random squiggly lines can tell you an accurate story about the heart, a mental search of Life in the Fast Lane’s rare ECG library, and glancing at the computer diagnosis to reassure you that your diagnosis is the compete opposite of theirs. This has a diagnostic success rate in the high 90s, so who could argue with it?

There is an opulence of texts and sites around to lead you through the specifics of each of the moieties of the ECG panorama. I recommend you avail yourself of one of these for the quotidian details.

To really understand something, though, one should pay homage to its history. It’s hard not to get excited by the scintillating backstory of the ECG with its 3 lead string galvanometric Einthovian beginning, which then evolved, barely, by the addition of several leads and a bit of Descartian mathematical wizardry. What is really fascinating, however, is how prodigiously little the ECG has changed over a century and a half. The paper result looks essentially the same. This is an unusual occurrence in human history. Change is the hallmark of we bipedal beasts. It is thought that what split Homo erectus, and then the fancy new hominid, sapiens sapiens, from its slightly embarrassing Neanderthal relatives, was the desire and ability to constantly change, particularly when it came to tools. Tools did not change one iota for a million years, then along came these upstart creatures wanting to get into the sophisticates’ club, and we can see their tools improve generation by generation. We are hardwired to want to change things. This goes quite some way towards explaining the behaviour of government departments, who prize rebranding, renaming, rezoning, and generally shuffling about of names and roles. Although perhaps is this, this transition to the illusion of change, where evolution, indeed, stops? Could we blame the end of evolution on administrators?

A peculiar element of ECG interpretation is the appearance of completely ‘new’ diseases within the last decade or so – syndromes that were allegedly not around when those more wizened of us trained. Wellen syndrome, ST elevation in aVR, Brugada syndrome, Spodick sign etc, as though these pathophysiological conditions have recently materialised out of nowhere. Where were they before? What did clinicians make of those distinctive ECG patterns? Did they just fob them off as non-specific changes, or simply ignore them as being wiggly annoyances?

Do check the leads are on the right way. Many a ponderously rare and fascinating diagnosis has been made by neglecting to recognise that pattern. If it’s all ass over elbow in the augmented unipolar leads then be suspicious.

Applying numerical criteria to ECG assessment should be done at your own risk. The sense of failure at STILL not being able to remember Brugada’s criteria holds a particularly heavy weight of shame. Other fanciful mathematical criteria can also be worked around by a robust system of alternatives. And a phone. Always carry a phone.

Make some leads your favourites. aVR is a good one for unveiling Very Bad Things. aVL is also rather nice, as even a sniff of sagginess in its ST’s is incredibly useful in the search for ischaemia. Not wishing to insult the others, but they really don’t pull as much weight, in my irregular opinion. If you are feeling adventurous, you can add more of them. Right sided, seven to nine, Lewis, all of them contributing more and more information.

Do not worry if you can’t tell the difference between some of the uncommon variants of heart block. Nobody can, although they may argue vociferously down the phone to the contrary.

Beware of the ECG shysters. Tremor artefact (do try to avoid shocking this), minuscule pacing spikes (no wonder you couldn’t apply the bloody Sgarbossa criteria), LVADs and heart transplants and machine malfunctions; all of these have a particular pattern, and are hilarious in ECG quizzes, but are not so amusing on the shop floor if unrecognised. Once you see a few though, your lovely brain will assist by storing them away in your hippocampal ECG drawer for retrieval, just when you need to look clever.

Let’s face it. The ECG is a formidable tool. To be able to translate the action of that muscle buried deep in the chest into a pulsing set of lines. It is the pounding, insistent song-sheet of the living. The heart as troubadour. One could argue that the ECG is an epic poem, Homeric perhaps, written in dactylic hexameter**, letting us read the thump of the heart, see it, diagnose the blocks and the beats and the hypertrophy and the strain and the weird things in the head and the strange things in the vessels, and probably new things in the future we haven’t even thought of. Next time you read one, fast, or slow, perhaps take a moment to consider its wonder.

* From the yet unpublished “Emergency Medicine: Thinking Fast and Weird”

** Now you may eye-rollingly dismiss this as just another of my faintly ridiculous metaphors, but bear with me. We thrive on metres. We comprehend things best in song. Dactylic refers to the fingers (long, short, short), and Homer wrote his magnificent epics (see, he too could be EPIC) with six of them per line. Very different from Shakespeare’s iambic pentameter (tee-TUM, five times over). Additionally, Homer was a master at creating visual-aural patterns to enable people to remember his poetry – consider the epithet ‘rosy-fingered dawn’. Dawn is only ever rosy-fingered, and is mentioned 20 times in the Odyssey. See? Actually, when it comes to it, perhaps you are correct after all…

‘How to…’ series. An Instruction manual for those in Critical Care

How to Read an ECG Michelle Johnston

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LITFL Review 334 https://lifeinthefastlane.com/litfl-review-334/ https://lifeinthefastlane.com/litfl-review-334/#respond Mon, 04 Jun 2018 18:47:47 +0000 https://lifeinthefastlane.com/?p=177567 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 334th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

LITFL Review 334 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 334th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsDon’t Forget the Bubbles features a powerful talk by Natalie May about patient needs and lessons we can learn from the culture of pediatric EM and their application in adult patients. [AS]

 

The Best of #FOAMed Emergency Medicine

  • Fantastic comprehensive approach to the care of the agitated patient featured on EM Updates. [AS]
  • EM Ottawa provides an excellent review of urgent care potpourri looking at the evidence on management of corneal abrasions, distal phalanx injuries and epistaxis. [MMS]
  • A patient with a clear cut acute coronary occlusion on EKG presents with a history of recent normal angiogram. Is this even possible? Dr. Smith gives some pearls to keep in mind when you are encounter this conundrum. [MMS]
  • Concussions can be emotionally impactful, especially for an active individual. EM Pulse gives a deep dive into concussion on what we can do to better assess, manage and counsel our patients in the ED. [MMS]
  • Could subdissociative-dose ketamine be a good strategy for moderate to severe pain management in geriatric patients, who are often not ideal candidates for opioid analgesia? Brian Hayes reviews a recent paper by Dr. Sergey Motov and colleagues. [SN]
  • Over at ICU Revisited, Aron Hussid reviews a recent JAMA article evaluating successful first-attempt intubation rates when using a bougie vs. endotracheal tube and stylet. [SN]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

  • Aidan Burrell reviews the EOLIA trial looking at ECMO in severe ARDS for The Bottom Line. An amazing trial which has left many more questions than answers… [SO]

The Best of #FOAMtox Toxicology

  • Got a case of sulfonylurea-associated hypoglycemia? This week’s Tox and the Hound post reminds us to reach for octreotide when rebound hypoglycemia occurs after dextrose boluses. [SN]

The Best of #FOAMus Ultrasound

  • Diastology can be a difficult concept to grasp! Save this diastology primer sheet by Stephen Alerhand next time you review this complicated topic. [MMS
  • Learn the potential life-saving stellate ganglion nerve block to keep in your armamentarium when dealing with ventricular storm. [MMS]

The Best of #FOAMpeds Pediatrics

Reference Sources and Reading List

Brought to you by:

LITFL Review 334 Marjorie Lazoff, MD

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Funtabulously Frivolous Friday Five 239 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-239/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-239/#respond Fri, 01 Jun 2018 05:18:37 +0000 https://lifeinthefastlane.com/?p=177513 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF...introducing Funtabulously Frivolous Friday Five 239.

Funtabulously Frivolous Friday Five 239 Neil Long

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 239.

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1

Who said ”My life is in the hands of any rascal who chooses to annoy or tease me” and why?

  • Dr John Hunter (1728-1793)
  • The Scotsman John Hunter is one of the greatest anatomists in history, he brought science to the art of surgery, is remembered as the most infamous of the resurrection men, and once described semen held in the mouth as “having a warmth similar to spices”.
  • Hunter suffered from angina pectoris and was not known for his ability to suffer fools well. As usual, he was right… Hunter died of a heart attack while attending a board meeting, during which he became irate at the opposition to the appointment of his successor at St. George’s Hospital.

Question 2

What is the ‘Kehoe principle‘?

  • The erroneous ‘Kehoe Principle’ can be summarised as:

“The absence of evidence of risk = Evidence of the absence of risk.”

  • Robert A. Kehoe, a toxicologist employed by the Ethyl Corporation, exemplified the ‘show me the data‘ mentality in defending the safety of leaded petrol. His stance was based on the rationale that there was no convincing published evidence of harm to humans. Subsequent research led to the complete removal of lead from gasoline in the United States by 1986. [Reference]

Question 3

During a pre-brief for your next simulation, the facilitator states we are going to implement ‘Chatham House Rule.’ What do they mean? 

  • ‘When a meeting, or part thereof, is held under the Chatham House Rule, participants are free to use the information received, but neither the identity nor the affiliation of the speaker(s), nor that of any other participant, may be revealed.’
  • The Chatham House Rule is a system for holding debates and discussion panels on controversial issues, named after the headquarters of the UK Royal Institute of International Affairs, based in Chatham House, London, where the rule originated in June 1927. [Reference]

Question 4

How did James Harrison save 2.4 million babies?

  • He donated plasma containing antibody for rhesus D so rhesus -ve mothers could be given Anti-D when required.
  • He donated 1173 donations for more than 60 years and on the 11th of May 2018 he gave his last. [Reference]
  • Listen to James Harrison here.

Question 5

Michael Jackson leans over to 45 degrees in his Smooth Criminal video. A trained dancer may be able to achieve 25 to 30 degrees. How did he achieve such a biochemically impossible dance move?

  • A specially designed shoe
  • Manjul Tripathi et al in India investigated the biomechanics and showed that such a move would put too much strain on the achilles tendon. The extra degrees were achieved by a special shoe and a hitch member.
  • He did also require some erector spinae strength training. [Reference]

…and finally

CrazySocks4Docs
CrazySocks4Docs

Funtabulously Frivolous Friday Five 239 Neil Long

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Mastering Intensive Care 030 with Francesca Rubulotta https://lifeinthefastlane.com/mastering-intensive-care-030-with-francesca-rubulotta/ https://lifeinthefastlane.com/mastering-intensive-care-030-with-francesca-rubulotta/#respond Wed, 30 May 2018 11:08:45 +0000 https://lifeinthefastlane.com/?p=177510 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Andrew Davies talks to Francesca Rubulotta about Mastering Intensive Care: clinical simplicity, passionate leadership, educational innovation, and more!

Mastering Intensive Care 030 with Francesca Rubulotta Andrew Davies

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Clinical simplicity, passionate leadership and educational innovation

In this week’s episode, you’ll hear an invigorating conversation with Francesca Rubulotta. This power-packed, enthusiastic, passionate, water polo-playing, Italian doctor, now living and working in London, UK, is seriously ambitious to help patients other than those in her ICU, mostly by advancing education using technological innovation.

Francesca is a Consultant and Honorary Senior Clinical Lecturer in Anaesthesia and Intensive Care Medicine at Imperial College Medical School. She studied medicine and anaesthesia in Italy and intensive care in Belgium, but also worked in the USA and the Netherlands on a journey that arrived in London 10 years ago. Francesca has been the Chair of the past division of professional development of the European Society of Intensive Care Medicine (ESICM) and is currently the Chair of the ESICM’s CoBaTrICE project. She leads and has led many other committees and organisations, and is presently the first ever female Presidential candidate in the ESICM general election (with the ballot open until June 11).

Francesca has diverse clinical interests including end of life care, ethical aspects of intensive care, rapid response systems, and clinical research. She speaks 5 European languages, travels and speaks around the globe and has won masters world championships as a waterpolo player.

In this conversation, Francesca demonstrates a deep understanding of, a strong passion for and substantial experience in running educational programs and courses in an innovative way using digital technology. She also tells of her desire to maximize the reach of education to less-developed areas of the world and her hope for more balance between the genders in intensive care. We also cover:

  • The story of her multinational career so far
  • How she obtained her current job in the United Kingdom
  • How her intensive care career began by translating her intensivist father’s slides into English as a high school student
  • How both she and her sister are now intensivists
  • The benefits of training under some of the superstars of intensive care
  • Her observation that the best intensivists keep it simple
  • A story about how her change in demeanour helped her team understand how a clinical situation had turned serious
  • The importance of empowering junior staff to make decisions
  • Her fundamental desire to have daily physical contact with each patient
  • How she took an ex-long-term ICU patient to the pub
  • Raised expectations that educators should now deliver TED-like talks
  • The honour of standing as an election candidate to be ESICM President
  • The possibility of a global intensive care society one day
  • Her passion for waterpolo and the vital importance of following our passions outside of medicine
  • How yoga helps her look after her mind
  • Learning from the mistakes she has made along the way
  • And some thoughts about gender inequality in intensive care

My genuine hope with the Mastering Intensive Care podcast is to inspire and empower you to bring your best self to work and to adopt some of the habits and behaviours my guests give their perspectives on, with the ultimate purpose of improving outcomes for all of our patients. Please help me to spread the message by simply emailing your colleagues, posting on social media or subscribing, rating and reviewing the podcast.

Feel free to leave a comment on the Facebook “mastering intensive care” page, on the LITFL episode page, on Twitter using #masteringintensivecare, or by sending me an email at andrew@masteringintensivecare.com.

Thanks for listening on the journey towards mastering intensive care.

Andrew Davies

——————–

Show notes (people, organisations, resources or links mentioned in the episode):

Link to Francesca Rubulotta’s ESICM President campaign: https://mailchi.mp/b3364cf0ed73/francesca-rubulotta-esicm?utm_source=mailchimp&utm_campaign=030026c6e1f0&utm_medium=page

Francesca Rubulotta’s logo, suggesting representation (globe), education (eye) and innovation (light):

Twitter handle for Francesca Rubulotta: @frubulotta

Mastering Intensive Care podcast: http://masteringintensivecare.libsyn.com

Mastering Intensive Care at Life In The Fast lane: https://lifeinthefastlane.com/litfl/mastering-intensive-care

Twitter handle for Andrew Davies: @andrewdavies66

Email Andrew Davies: andrewATmasteringintensivecare.com

Mastering Intensive Care 030 with Francesca Rubulotta Andrew Davies

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Medmastery: Alveolar disease https://lifeinthefastlane.com/medmastery-alveolar-disease/ https://lifeinthefastlane.com/medmastery-alveolar-disease/#respond Wed, 30 May 2018 09:58:56 +0000 https://lifeinthefastlane.com/?p=177280 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

This short Medmastery video from the Mechanical Ventilation Essentials course provides key observations related to managing ventilated patients with airway disease and/or alveolar disease.

Medmastery: Alveolar disease sabrine

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

The team at Medmastery are providing LITFL readers with a series of FOAMed courses from across their website.

Today we’re again looking at the Mechanical Ventilation Essentials course with a video offering key observations related to managing ventilated patients with airway disease and/or alveolar disease.

Further reading:

Guest post: Josh Cosa, MA, RRT-ACCS, RRT-NPS, RCP. Registered respiratory therapist and respiratory care practitioner, Clinical Education Manager at Philips.

I received my license to practice in 2003 and I have been teaching, managing, monitoring, and modifying ventilator settings ever since. I live in Southern California and have learned from and worked with some of the best teachers anyone could meet.” –Josh Cosa

Medmastery: Alveolar disease sabrine

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LITFL Review 333 https://lifeinthefastlane.com/litfl-review-333/ https://lifeinthefastlane.com/litfl-review-333/#respond Sun, 27 May 2018 23:53:51 +0000 https://lifeinthefastlane.com/?p=177443 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 333rd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

LITFL Review 333 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 333rd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsThis is an absolutely fantastic and succinct review of non-invasive ventilation in critical care, written by Dr. Anthony Hackett at PulmCCM. [RP]

The Resus Room podcast has another installment in their Roadside to Resus series. This one reviews everything we need to know about paediatric arrest. [MG]

The Best of #FOAMed Emergency Medicine

  • Excellent review from Taming the SRU on the ABG vs. VBG debate. Great reference to keep handy when asked for an ABG. [AS, SR]
  • The Trauma Professionals Blog has a two-part post about something we take for granted: automated blood pressure cuffs. How do they work, and how accurate are they? The answers may surprise you. [MG]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

  • Josh Farkas takes a hatchet to some classic dogmatic teachings in neurocritical care including “GCS 8, must intubate,” 3% hypertonic saline via a peripheral IV, and the benefit of lytics in ischemic stroke. [AS, SR]
  • Should we be treating fevers in sepsis? Emily Damuth at EMDaily reviews bench data and the HEAT trial and argues for restraint with your acetaminophen order. [RP]
  • Anton Helman and Scott Weingart sit down and discuss common airway pitfalls and how to be prepared and overcome them. 40 minutes of gold with high yield airway pearls. [SR, MG]
  • Justin Morgenstern does a nice literature review on the safety of peripheral vasopressors in critically ill patients. Extravasation can occur (2 – 6%). [SR]
  • There is an updated review of super-refractory ventricular tachycardia and its management from Deranged Physiology. Therapies discussed range from amiodarone to phenytoin, cardioversion to sympathectomy, presenting management pearls steeped in evidence as well as some “kitchen sink” remedies. [TCN]
  • TXA is good for everything, right? The TICH-2 study looks at TXA use in primary ICH, and EM Lit of Note and St. Emlyn’s feature excellent critiques and suggestions for your practice. [AS]

The Best of #FOAMtox Toxicology

  • Your local toxicologist or poison control are always available at (800) 222-1222, but in case you need to refer to a concise and comprehensive antidote dosing chart, ACMT has an excellent resource for you. Note that the chart is from 2015. [MMS]

The Best of #FOAMus Ultrasound

The Best of #MedEdFOAM and #FOAMsim

Reference Sources and Reading List

Brought to you by:

LITFL Review 333 Marjorie Lazoff, MD

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Funtabulously Frivolous Friday Five 238 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-238/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-238/#respond Thu, 24 May 2018 22:30:12 +0000 https://lifeinthefastlane.com/?p=177021 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF...introducing Funtabulously Frivolous Friday Five 238.

Funtabulously Frivolous Friday Five 238 Neil Long

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 238.

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1:

What ‘club-shaped’ organism, the cause of a ‘leathery’ disease, killed about 4000 people in the former Soviet states between 1991 and 1996?

  • Diphtheria caused by the exotoxin of Corynebacterium diptheriae.
  • An epidemic swept through the former Soviet states due to a number of factors: decreased immunisation rates and the breakdown of public health; waning immunity in adults who were vaccinated as children; poor socioeconomic conditions; population movements; and the resurgence of more toxic strains. [Reference]
  • Korynee = club (refers to the organism’s shape), diptherite = greek for leather (refers to the greyish membrane that is usually present – classically in the pharynx).
Click on the photo to link to DIPNET the diphtheria surveillance website.

Question 2

How did Le Fort develop his classification of facial fractures?

  • René Le Fort (1869 – 1951) was a French surgeon employed a number of different wounding agents which included a wooden club, a kick, a metal shaft and projecting the head against the corner of a marble table to develop the Le Fort classification of facial fractures.
  • Contrary to popular belief there were no cannon balls, mine shafts or bricks used.
  • The breakdown of his detailed 35 experiments in 1900 are as follows:
    • Metal shaft versus face = 1
    • Kick to the face = 2
    • Head versus corner of marble table or dissection table = 4
    • Head in a vice and tightened = 5
    • Wooden club to the face = 23 [Reference 1, Reference 2]

Question 3

What is selfitis? 

  • A genuine mental condition whereby people feel compelled to continually post pictures of themselves on social media.
  • Originally a hoax, the term was first coined in 2014 as a spoof news story. Following on from this, researchers at Nottingham Trent University and Thiagarajar School of Management in India discovered it to be a true phenomenon.
  • What is your level of selfitis?
    • Borderline – Taking photos of one’s self at least three times a day but not posting them on social media.
    • Acute – Taking photos of one’s self at least three times a day and posting each one on social media
    • Chronic – Uncontrollable urge to take photos of one’s self round the clock and posting the photos on social media more than six times a day. [Reference]

Question 4

Time is a healer (as they say), but is it faster during the day or night?

  • The daytime.
  • According to an observation study on burns patients, those who sustained the injury during the day healed faster (17 days versus 28 days if it was sustained at night).
  • Their theory postulates, the cellular clock modulates the efficiency of actin-dependent processes such as cell migration and adhesion, which ultimately affect the efficacy of wound healing. [Reference]
  • On a similar theme, another research team found less adverse affects when heart surgery was performed in the afternoon versus the morning (28 out of 298 vs 54 out of 298). [Reference]

Question 5

A defensive mucus secreted by slugs has inspired what medical invention?

  • Glue that sticks on wet surfaces.
  • The university’s Wyss Institute for Biologically Inspired Engineering turned to the “Dusky Arion” slug, which creates sticky mucus as a defence against predators.
  • The incredible stickiness comes from the trinity of the attraction between the positively charged glue and negatively charged cells in the body; covalent bonds between atoms in the cell surface and the glue, and the way the glue physically penetrates tissue surfaces. [Reference]
  • A team in Harvard University have used it to glue a hole in a pigs heart successfully.

…and finally

Courtesy of Strata5 on twitter

Funtabulously Frivolous Friday Five 238 Neil Long

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Eponymythology: Second-degree AV block https://lifeinthefastlane.com/eponymythology-second-degree-av-block/ https://lifeinthefastlane.com/eponymythology-second-degree-av-block/#respond Thu, 24 May 2018 03:41:45 +0000 https://lifeinthefastlane.com/?p=177394 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

We review the early development of arrhythmia recording and the contributions of Luciani, Galabin, Gaskell, Wenckebach, Hay and Mobitz to the current terminology associated with the categorization of Second-degree Atrioventricular block

Eponymythology: Second-degree AV block Ben Mackenzie

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Eponyms can be confusing and open to misinterpretation. By plotting the historical course of their folksonomic semantic derivation we gain a deeper understanding of the condition, the authors and the eponym.

We review the early development of arrhythmia recording and the contributions of Luciani, Galabin, Gaskell, Wenckebach, Hay and Mobitz to the current terminology associated with the categorization of Second-degree Atrioventricular block

Current terminology

Mobitz Type I (Wenckebach AV block)

  • Progressive prolongation of the PR interval culminating in a non-conducted P wave
  • PR interval is longest immediately before the dropped beat
  • PR interval is shortest immediately after the dropped beat

Mobitz Type I Wenckebach

Mobitz Type II (Hay AV block)

  • Intermittent non-conducted P waves without progressive prolongation of the PR interval
  • PR interval in the conducted beats remains constant.
  • P waves ‘march through’ at a constant rate.
  • RR interval surrounding the dropped beat(s) is an exact multiple of the preceding RR interval (e.g. double the preceding RR interval for a single dropped beat, treble for two dropped beats, etc).

Mobitz Type II Hay

  • Arrows indicated ‘dropped’ QRS complexes (i.e. non-conducted P waves).
  • Type I and Type II describes the ‘ECG pattern’ and the anatomical site of the block should not be inferred by this

History

1873Luigi Luciani demonstrated cardiac group beating which he named ‘periodic rhythm’ whilst studying frogs’ hearts in Carl Ludwig’s laboratory in Leipzig. Luciani used a tonographic apparatus for the graphic representation of the ventricular pulse of the frog heart preparation [1873;25:11–94]

Luciani Periods 1873
Luciani Periods (Right to left) 1873
  • Periodic ventricular rhythm shown by frog heart tied at atria 2mm above AV groove, filled with rabbit serum, and attached to tonographic apparatus – Luciani 1873
Upshaw Silverman interpretation of Luciani periods AV Block
Upshaw Silverman interpretation of Luciani periods AV Block. Circulation. 2000;101:2662-2668
  • Ventricular pulse waves of Luciani groupings (with pause) taken from the original figures and enlarged 8x. Upshaw and Silverman created a laddergram (drawn beneath the waves) which illustrates Wenckebach second-degree AV block. Circulation. 2000;101:2662-2668

1875Alfred Galabin was the first to demonstrate atrioventricular block in humans. He used the apexcardiogram to study patients with mitral stenosis and found a patient (Richard B-) with a slow pulse; the case report in which he described atrial contraction asynchronous with ventricular contraction. [1875;20:261–314]

Subsequent analysis of Galabin’s studies suggest his patient had advanced AV block with 3-to-1 and 2-to-1 AV conduction with Wenckebach periodicity

Galabin Apexcardiogram of Richard B-

  • Richard B-, was a 34 year old male who presented with a pulse of 25-30 bpm. Figure 14 (XIV) demonstrates ‘wavy movements’ in the long diastolic interval and could be attributed to movement artefact. However a repeat study taken later in the same day, figure 15 (XV), demonstrates an almost exact repetition.
  • Galabin postulated that the atria of the heart contracted twice in the interval between two ventricular contractions, and sometimes singly in the midst of a long pause instead of just before the systole of the ventricle.

1898Karel Wenckebach consulted a 40-year-old woman with an irregular pulse which he interrogated using a sphygmogram and tuning fork. He noted there were regular pauses every 3 to 4 beats, but the small extra pulse seen during pauses were longer, and subsequent intervals were smaller. The first interval after each pause was longer, and subsequent intervals were shorter.

Wenckebach credited Luciani as the first to describe this recurrent pattern in his 1873 frog heart experiments and defined this form of group beating as Luciani periods [1899;37:475–488 and 1900;39:293-305]

Wenckebach periodicity Type I AV block
Wenckebach periodicity – Type I AV block
  • Wenckebach’s figure demonstrates a constant atrial rate (top line) with diagonal lines (representing AV conduction) progressively lengthening before a beat being missed/dropped. This is followed by the recommencement of the cycle.
  • With the advent of electrocardiography in the early 20th century, this form of group beating became known as ‘Wenckebach periodicity‘ and later as ‘Mobitz type I atrioventricular block‘.

1906John Hay kymographically recorded simultaneous jugular venous and radial arterial pulses of a 65-year-old man with a slow pulse. He observed that the a-to-c intervals of the jugular venous waves remained constant until an a (jugular venous) wave occurred that was not followed by the c (radial pulse) wave. The pause was equal to 2 atrial pulse-wave intervals [Lancet 1906;167(4299):139-143]

John Hay AV Block Type II

Dr John Hay AV Block Type II

  • 1906 – Wenckebach acknowledged Hay’s report, and suggested that the pauses found in Hay’s patient were the result of both abnormal AV conduction and abnormal ventricular excitability. [Archiv für Physiologie 1906:332]
  • Hay had also spent six month’s studying with Wenckebach at Freiburg.

1924Woldemar Mobitz applied a mathematical approach to analyzing arrhythmias by graphing the relationship of changing atrial rates and premature beats to AV conduction and in 1924 he classified second-degree atrioventricular (AV) block into 2 principle types, subsequently referred to as Mobitz type I (Wenckebach) and Mobitz type II (Hay). [1924;41:180-237]

Mobitz Type I Wenckebach 1924
Type I AV Block: Laddergram and cardiac rhythm strip – Mobitz 1924.
  • The top line of the laddergram demonstrates the time between atrial contraction (equivalent to P-P intervals) to be constant.
  • The middle diagonal line depicts AV conduction (P-R interval), which gradually lengthens until the point at which AV conduction is absent altogether. After this point, the cycle starts again.
  • The bottom line of the laddergram illustrates increasing time periods between ventricular contraction (R-R interval), before a long pause as a result of the dropped beat, followed by a repeat of the cycle.
  • Effectively a 6:5 Type I block.

Mobitz Type II Hay 1924
Type II AV Block: Laddergram – Mobitz 1924.
  • Atrial rate is constant, AV conduction rates are constant when successful, and ventricular contraction is present only after successful AV conduction.
  • The rate of ventricular contraction is the same as rate of atrial contraction, or where AV block occurs, is an exact multiple of the atrial rate, as below algebraically

Mobitz Type II Hay block 1924

Associated Persons

Controversies

  • An apparent and remarkable absence of controversy, with frequent acknowledgement of the work of both their preceding and contemporary colleagues.
  • Despite a well defined historical timeline only the names of Wenckebach and Mobitz remain in common use

References

LITFL Related Links

Eponymythology: Second-degree AV block Ben Mackenzie

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Medmastery: Volume vs Pressure Control https://lifeinthefastlane.com/medmastery-volume-pressure-control/ https://lifeinthefastlane.com/medmastery-volume-pressure-control/#respond Wed, 23 May 2018 09:44:15 +0000 https://lifeinthefastlane.com/?p=177276 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

In this video from Medmastery's Mechanical Ventilation Essentials course, explore why volume control is the preferred initial breath type of ventilation.

Medmastery: Volume vs Pressure Control sabrine

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

The team at Medmastery are providing LITFL readers with a series of FOAMed courses from across their website.

Today we explore the Mechanical Ventilation Essentials course with a video explaining why volume control is the preferred initial type of ventilation Assist control (AC) and synchronized intermittent mandatory ventilation (SIMV) modes

Further reading:

Guest post: Josh Cosa, MA, RRT-ACCS, RRT-NPS, RCP. Registered respiratory therapist and respiratory care practitioner, Clinical Education Manager at Philips.

I received my license to practice in 2003 and I have been teaching, managing, monitoring, and modifying ventilator settings ever since. I live in Southern California and have learned from and worked with some of the best teachers anyone could meet.” –Josh Cosa

Medmastery: Volume vs Pressure Control sabrine

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LITFL Review 332 https://lifeinthefastlane.com/litfl-review-332/ https://lifeinthefastlane.com/litfl-review-332/#respond Sun, 20 May 2018 22:40:35 +0000 https://lifeinthefastlane.com/?p=177313 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Welcome to the 332nd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the web

LITFL Review 332 Marjorie Lazoff, MD

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

LITFL review

Welcome to the 332nd LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chunk of FOAM.

Readers can subscribe to LITFL review RSS or LITFL review EMAIL subscription

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsPulmonary embolism risk stratification is a must when working up your patients. FOAMCast goes over the current guidelines, while the latest SGEM episode discusses the PROPER trial with guest skeptic Jeff Kline. [MMS]

The Best of #FOAMed Emergency Medicine

  • In this post from ALIEM, the case is made regarding ketamine for ethanol withdrawal. There is a review of the pathophysiology of ethanol withdrawal and how ketamine works in the CNS. Three studies are detailed and their results would indicate there is a potential benefit of ketamine in select ethanol withdrawal patients. [TCN]
  • Rory Spiegel dives into a hot off the press publication on bougie first intubation. It may be time for a paradigm shift of bougie as a rescue device. [SR]
  • Clay Smith reviews a recent paper on atraumatic needles for lumbar puncture. Why are we still using the standard LP needles that come in the kits? [SR]
  • Justin Morgenstern is at it again reviewing some papers of the month for May 2018. If you want to hear the audio version checkout his podcast with Casey Parker over at broome docs. [SR]
  • Which abscess needs antibiotics? Which need to be drained? How should they be drained? Rob Bryant gives a fantastic literature review of these questions in the ever-changing evolution of abscess management. [MMS]
  • Here’s EMCrit’s podcast on Part II of TTP and DIC, which features Tom DeLoughery’s treatment recommendations. [SN]

The Best of #FOAMcc Critical Care and #FOAMres Resuscitation

The Best of #FOAMtox Toxicology

  • The Tox and the Hound blog reviews a common but often mis/underdiagnosed entity: alcoholic ketoacidosis (AKA). [AS]

The Best of #FOAMus Ultrasound

The Best of #MedEdFOAM and #FOAMsim

  • Nervous about your next presentation? Check out these top seven tips on rehearsing your presentation on the first Medutopia blog post. [MMS]
  • Mike Gisondi discusses strategic planning to foster critical changes in your educational leadership teams to become harder, better, faster, stronger. [MMS]

Reference Sources and Reading List

Brought to you by:

LITFL Review 332 Marjorie Lazoff, MD

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Funtabulously Frivolous Friday Five 237 https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-237/ https://lifeinthefastlane.com/funtabulously-frivolous-friday-five-237/#respond Thu, 17 May 2018 22:04:09 +0000 https://lifeinthefastlane.com/?p=177002 LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF...introducing Funtabulously Frivolous Friday Five 237.

Funtabulously Frivolous Friday Five 237 Neil Long

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LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF…introducing Funtabulously Frivolous Friday Five 237.

Readers can subscribe to FFFF RSS or subscribe to the FFFF weekly EMAIL

Question 1:

  • Charles Heber McBurney (1845 – 1913)
  • The seat of greatest pain, determined by the pressure of one finger, has been very exactly between an inch and a half and two two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus” – McBurney 1889 [Reference]

Question 2

Which anaesthetist published a neonatal scoring system commonly used today in 1953?

  • Virginia Apgar (1909 – 1974)
  • APGAR is the (b)acronym for the eponym
  • The APGAR scoring system is a comprehensive screening tool which should be used to assess newborns at birth and can assist in identifying the need for any immediate attention/ intervention that baby needs.
  • The original work published by Apgar in 1953 described the five variables as heart rate, respiratory effort, reflex irritability, muscle tone and colour. In 1961 Apgar received a letter from Dr Joseph Butterfield a professor at the Colorado University in Denver which informed her that one of his residents had devised an acronym connecting the five letters of her surname to the five evaluations of the newborn…APGAR. [Reference]

Question 3

A son of an innkeeper described the effectiveness of chest percussion for diagnosing certain respiratory ailments. Who was he? 

  • Josef Leopold Auenbrugger von Auenbrugger (1722 – 1809)
  • Auenbrugger is said to have tapped wine barrels in his father’s cellar as a boy to find out how full they were.
  • Auenbrugger validated his clinical observations on the use of diagnostic percussion by:
    • comparing clinical assessments with post-mortem findings
    • injecting fluid into the pleural cavity of cadavers to demonstrate that percussion could accurately define the physical limits of any fluid present.
  • Unfortunately his work was largely unheralded at the time. His teacher (Van Swieten) in 1764 and 1772 major treatises on ‘pulmonary chills and chest water’ failed to mention Auenbrugger. Similarly De Haen, who was the head of the medical clinic in Vienna from 1754-1776 makes no comment on percussion in “Ratio Medendi In Nosocomio Practico Vol I to VIII” ironically complaining “how dark and difficult is the diagnosis of the thoracic water, the pleuritic and pericardian exudates.
  • It was not until a French translation by Jean-Nicolas Corvisart des Marest, personal physician to Napoleon, appeared in 1808 that the diagnostic method gained worldwide acceptance. Corvisart taught the method of percussion to his students and in 1808 translated and published the book with annotations a year before Auenbrugger’s death. [Reference]

Question 4

Which heavy metal accumulates in the lenses of the eyes of smokers?

  • Cadmium.
  • The accumulation of copper, lead, and cadmium occurs in cataract.
  • The probable source of cadmium in humans is cigarettes.
  • Lenticular cadmium accumulation also increases copper and lead precipitation in the lens. Cigarette smoking might be cataractogenic. [Reference]

Question 5

Do identical twins have identical fingerprints?

  • No
  • To a standard DNA test, they are indistinguishable. But any forensics expert will tell you that there is at least one surefire way to tell them apart: identical twins do not have matching fingerprints.
  • Genetics helps determine the general patterns on a fingertip, which appear as arches, loops and whorls. While a foetus is developing, the ridges along these patterns are influenced by a number of factors, including bone growth, pressures within the womb and contact with amniotic fluid. [Reference]

…and finally

Choose Wisely

Funtabulously Frivolous Friday Five 237 Neil Long

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