Ketamine Fight Club: Ketamine in TBI

Ketamine Fight Club: Ketamine in TBI

There has long been a concern for increases in ICP with administration of ketamine primarily stemming from reports of increased ICP in the Neurosurgery and Neuroanesthesia literature.  These increases were described primarily in patients usually with CSF outflow obstruction undergoing elective neurosurgical procedures.  In the time since these articles were published, the use of ketamine in a wide variety of patients with neurologic compromise has been reported.  In fact, there have been a couple of recent systematic reviews and meta-analyses on this topic.  These systematic reviews and meta-analyses have essentially analyzing all the same existing literature (which is generally poor in quality).  

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Might As Well Face It: We’re Addicted to SMACC

SMACC Chicago

Social Media And Critical Care

Here at Taming the SRU, where we’ve been SMACC-infatuated for more than a year now, it’s easy for us to forget that many of you out there are still unfamiliar with what the fuss is all about.  SMACC is the Social Media and Critical Care conference.  Its next iteration, the third annual (and first to occur in North America), is coming in late June in Chicago, and wild horses couldn’t keep us away.  Taming The SRU is honored and stoked to be an Affiliated SMACC Website.

Isn’t this just another CME conference, you ask?  Emphatically, no.  Weingart has called it “simply the greatest medical conference in the history of the world,” and we don’t think this is hyperbole.  SMACC aims not only to educate; SMACC aims to entertain, and mostly, to inspire.  To quote smacc.net.au: “SMACC is a high impact academic meeting fused with cutting edge online social media to deliver innovation with education.  The underlying ethos is to provide free online education with open access, in what has come to be known as ‘FOAM’ (Free Open Access Meducation).”  Get this: all sessions will be recorded and released as videos or podcasts online on the affiliated SMACC websites following the actual conference, for free!  And yet, hundreds of us will flock to Chicago to attend in person.  Why?  We’re addicted to the inspiration of FOAMed, and the maximum dose of this inspiration attainable is SMACC, live and in person.  (Plus, we’re sick of just ‘favoriting’ Minh Le Cong’s Tweets, and we want to shake his hand or give him a big ‘ol bear hug.)  This is not your father’s medical conference.  It’s infinitely better.

SMACC also aims to connect people across boundaries, and succeeds in doing so like no conference ever has.  Wherever you practice critical care (prehospital, ED, OR, ICU), SMACC is for you.  Whatever your discipline (student, EMT, medic, nurse, PA, NP, CNS, CRNA, doc), SMACC is for you.  Whatever your specialty, whatever your experience level, whatever country you call home, whatever your clinical setting: as long as you seek inspiration to be as good as you can be at optimizing your sick patients’ outcomes,  SMACC is for you.  Right now, go to the brochure and look at it for just 60 seconds.  Can you get a witness?  You bet.  Listen to this brief podcast in which Bill Knight, Jeff Hill, and I testify about the reasons for our excitement about our upcoming road trip to Chi-town.  Still not sure?  Check out the archives from SMACC 2014 (Gold Coast, Australia).  We think you’ll be convinced.  But, be forewarned: there’s no cure for SMACC addiction.

Prehospital Care, An International Perspective

Prehospital Care, An International Perspective

The State of Affairs

     The morbidity and mortality of trauma on a global perspective is humbling.  Aside from HIV/AIDS and TB, trauma is the chief cause of mortality for 15 to 45 years of age (based on 2002 WHO data).  5.8 million deaths annually.  5.2 million of those deaths, or 90%, occur in low-and-middle-income countries (LMIC’s).  Prehospital care in LMIC’s varies immensely.  Total prehospital time, the training level of prehospital providers, transportation method, and access to emergency medical systems (EMS) are some of the better described aspects of prehospital care in LMIC’s.  The attributes of the prehospital health care delivery system differ significantly on a country by country basis.

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Cyanide Poisoning - Recognition and Treatment

Cyanide Poisoning - Recognition and Treatment

Hey everybody! Dr.’s Hinckley, Steurwald, and myself sat down recently to talk a little bit about hydroxocobalamin (Cyanokit) and put together the attached podcast. 

Here are a few take home points and additions regarding this cherry-colored elixir of wonder: 

  • Think about hydroxocobalamin in your hemodynamically unstable or otherwise SICK patients who have a history of smoke exposure in an enclosed space or a known industrial exposure to CN containing material. This stuff works fast and can be life saving.
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EMS Scope of Practice

EMS Scope of Practice

Recently, I had the pleasure of sitting down with Dr. Dustin Calhoun, EMS faculty member within the Department of Emergency Medicine at the University of Cincinnati.

Dustin had been responsible for an EMS fellow didactic session covering EMS scopes of practice and EMS licensure. While on the surface these topics may seem a bit “boring,” I found our examination of the complexities quite interesting. In fact, I found the session so useful that I asked Dustin to record this podcast with me (and I’m a former EMT!).

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Neurologic Emergencies in the Air

Neurologic Emergencies in the Air

Several months ago, I sat down and talked about the management of neurologic emergencies in the prehospital environment with Dr. Erin McDonough, an Emergency Physician and Neurointensivist who attends both in the ED and the Neurosciences ICU, and is a member of the Cincinnati Stroke Team.  In the brief podcast found below and on iTunes, we covered a wide range of topics including blood pressure management in spontaneous ICH, aneurysmal SAH, and ischemic stroke and some of the more rare complications associated with tPA administration.

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Liquid Plasma aka "Never Frozen Plasma"

Liquid Plasma aka "Never Frozen Plasma"

I recently had the pleasure of sitting down with my co-EMS fellow, Dr. Ryan Gerecht, to discuss his experience with the implementation of a new blood product on our HEMS service: Liquid Plasma. Ryan was responsible for this implementation while serving as a Resident Assistant Medical Director during his last year of EM training at UC (2013-2014).

Here is what Ryan has to say…

In the Emergency Department, ICU, or operating room what do you resuscitate the hemodynamically unstable, bleeding trauma patient with? What about the patient with a massive GI bleed or ruptured AAA? How do you manage the patient with an intracerebral hemorrhage on Coumadin? (assuming you don’t have PCC’s readily available)

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Logistics are Critical

Logistics are Critical

Not much gets me as fired-up anymore as trying to optimize them. While I like to think that it’s because they are integral to our mission and are the ultimate weapon in our quest to go from “good to best”, it’s really just my borderline OCPD (just kidding…sort of).

Long story short, I spend a lot of time thinking about clinical and operational logistics in HEMS – it’s become my thing. My goal with this post is to share some of that thinking with others who might want to build off of our ideas in hopes that those colleagues (i.e. you) will share their ideas that they are really excited about with us at some point.

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The Glories of End Tidal CO2

The Glories of End Tidal CO2

If you were to choose one vital sign for your critically ill patient, what would you choose?  Blood pressure?  Pulse?  Respiratory rate?  O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.

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Sepsis in the Air

Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

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The Myth of the Stable STEMI Transfer

The Myth of the Stable STEMI Transfer

We fly/transfer many patients with STEMI on Air Care and Mobile Care.  And, fortunately, a majority of these patients end up doing very well.  You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident.  You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport.  Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport.  To do so would be folly.

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Running a Code (in Tight Quarters)

Running a Code (in Tight Quarters)

How many hands does it take to run a code?   Think about that for a bit...

In the SRU, the available hands seem essentially limitless.  There's a train of PCAs and medical students lined up to perform CPR, a nurse to run the monitor and defib, a nurse and/or pharmacist pulling up meds and mixing drips, a nurse charting, a MD dedicated to the airway, a RT to help with bagging, not to mention the MD running the whole show.  At a minimum you probably have 10 hands ready to ensure compressions are as uninterrupted as possible, to keep a check on the respiratory rate, to hook up monitors, push meds, defib, and all the other tasks that are necessary to code a patient.

Now what do you do in the back of the helicopter when a patient loses a pulse?

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Prehospital TBI - Beyond the "Code"

Prehospital TBI - Beyond the "Code"

Of the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging.  Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics.  In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury.  This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.

To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:

  1. NO Hypoxia (SpO2 < 90%) – therefore, apneic oxygenation for all TBI patients
  2. NO Hypotension (sBP < 90 mmHg) – greatest iatrogenic risk is with induction and provision of positive pressure ventilation
  3. Blown pupil -> Hyperosmotic therapy + Hyperventilate
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Video Laryngoscopy in the Field? Absolutely

Video Laryngoscopy in the Field? Absolutely

Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight.  You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway.  He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's.  You start to look and assess the patient's airway and you are decidedly less than pleased.

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Rescue Me

Rescue Me

Extraglottic devices are often term "rescue devices."  And I can't decide whether this is a term that glorifies or degrades.  While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you.  And you think you can hold C-E mask seal while bagging for 20 min?  If you can, you must have hands that rival the late great Andre Rene Roussimoff...

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