Renal Emergencies

Dr Debajyoti M. Roy is a renal physician at Changi General Hospital and he's kindly given us permission to cast his talk on renal emergencies in the ED. A tour de force on balanced solutions, practical management, differences between AKI/CKD & dialysis complications.

OMI - God!

This is a recorded zoom talk from the EM Sling online conference in December 2020. Different times call for a different style of conferencing for a topic in which you can make a difference. 

Ever think that patient with a subtle TWI in AVL could have been “cathed” earlier? Is it always 2mm elevations or will something less do? Can you convince anyone that a deWinters wave is trouble brewing?

If so, then maybe you are a growing part of the EM populace which thinks that STEMI or NSTEMI doesn’t quite cut it as a sole paradigm for coronary intervention.

Heretic or convert or something in between… I offer no miracles - only perspectives.

Other links on this topic:

1. The original OMI Manifesto

2. LITFL - replacing the misnomer

3. Fantastic rap version of how to OMI!

The Great Disruptor: Covid-19

Covid-19 will be long remembered by this generation. This low lethality but high impact event has left a scar not only on medical fields but theplanet itself. Thoough suffering from a second wave currently, Singapore has a well documented way of dealing with this and our ED/hospital "positives" can be summarised into:

• Good command and control from the beginning
• One source of Information/dissemination + Updated info passed onto the floor daily
• Swab & Go protocols 
• Segregation of fever & non fever areas in the ED
• Fever area - PPE is gown / gloves /N95 / face goggles or shield
• Resus - PPE is N95 / gloves
• Resus (intubating and arrests) - PAPR with N95
• Non fever areas - Surgical mask and gloves

Other good resources:

The original article of the index cases

Handbook by Chinese hospitals

Covid calculators

Johns Hopkins datacentre


Probably the best video you can get on the subject is this detailed look into the pathophysiology and management by ESICM:




And finally when to ECMO:

Nul pointes..... the zero point survey?

Cliff Reid surmises that preparing yourself BEFORE the stress and immediacy of critical care tasks. Zen achieved via zero points...  survey that is.
Not just for pre-hospital teams but also for ED situations.

Ventilation guide Ver. 2

An update of our ventilation guide is now available here (pdf).
Version 2 includes nods to new techniques as well as ventilation strategies for difficult or rarer conditions. As always this is free for download and replication/alteration for your purposes.

Webucation 5/9/18

This episode of webucation gives us insights into old diseases and new. From cardio to dermatology and from myth to righteousness. Credit as always to the original content providers.

• Resuscitation communication - why its as important as any other treatment
• 4th Universal definition of MI - if you deal with heart attacks, you probably want to know this
• Simplifying mechanical ventialtion - great guide on the basics
• Myths of heart failure - still believing in some of these? 
• Moral injury - are you at risk of this or is it something we just live with?
• The migraine cocktail - catch up with the latest admixture for this pesky pathology

• Severe cutaneous reactions - a great run through one of my blindspots - dermatology. It sets out the differences and nuances of treatment of SJS / TENS etc

Sepsis checklist/bundle

Management of sepsis is an ever evolving science but the implementation of  such measures in the ED can be challenging as there are so many moving parts.
Here's our version of a bundle to recognition and management. Comments welcome as always.
The checklist can be downloaded here.

There is no spoon?

Prof. Rinaldo Bellomo is extremely well published and speaks here at SMACC Berlin in a Matrix like talk on physiological belief.
Some great lines here and some well thought out arguments. Chiefly, "we make the measurable important but not the important measurable". Thanks to the SMACC team for making this available.

Webucation 5/5/18

Web wisdom this round comes from gurus in EBM, critical care, trauma and even some philosophers on the state of affairs in medical education/administration. Credit as always to the original content providers.

• Breech delivery - info for when you need it!
• High flows you should know - all about BiPap and the new-ish HFNC
• The top 10 trauma papers - compiled by St Emlyn's
• Shrug it off - a novel technique for your subclavian needs
• The tPA drug war without end - controversial because science clashes with dollars
• UTI pearls and pitfalls - you'l be surprised at what you learn about "simple" things

• The trouble with mindfulness - one of the best articles I have read recently relating to error prevention and human behaviour. Well worth a read even if not in a "medical" mood.

Ortho damage control

Nice vid on damage control surgery from the orthopaedic standpoint. Dr Ebraheim's other educational videos can be found here.

Webucation 30/8/17

Webucation this time comes from subjects encompassing departmental ethos, paediatric and adult trauma, ECG dilemmas and even TED talk skills. As always credit to the original content creators. Do visit their sites.

• What really happens to a SAH?
• Pseudo lung point on U/S
• Bouncing kids and their injuries
• Don't kill your audience with bulletpoints
• STEMI or not STEMI... that is the question
• Is it ever too late to trauma activate?

• Nurse led codes
• What if your child had an arrest (this is a "must hear")

The last 2 links are worth the listen on your way home or on a jog. They describe and portend resuscitation at its best when elements align. Both talks show what can be if we get the heady mix of training, tech and guts right.

Cantor being candid

Richard Cantor is one of the gems in paediatric EM talks. His candour combined with raw experience are always at the forefront. His lessons just may prolong your career and a little one's life.

Kudos to a course well done

Most workshops will leave you with some valuable skills and insight. Plus you meet like minded people from all over the world!

To that effect, I highly recommend the APELSO Hong Kong ECMO course. Run by staff from Queen Mary/Grantham hospitals, it was exemplary in demystifying and deciphering everything extra-corporeal. Just like the excellent Reanimate, this course combines didactics, simulation and practical exercises but lasted for 5 days rather than 2. Here's some pics taken with permission. 

Dr Thomas Mueller's (Regensburg, Germany)
take on ECPR

Full circuit with dedicated Apps for simulating monitors

Veno-Arterial circuit with reperfusion cannula 

Scenarios were realistic and focused on basics of troubleshooting

They even brought in fluroscopy in the sims

Transportation sim for interhospital transfers on circuit 

Live action mannequin for the sims - can't get more fidelity than that

Cannulation combined with nursing and CPR team

You can sign up for more courses like this here if interested in ECLS.

Shocking updates

1. New look for the website. Have been experimenting with some designs lately so apologies for changing look.
2. We'll have a few more posts from new contributors to this site. So stay tuned for more radiology quizzes and resident perspectives.
3. To add to our guides on common ED drugs and ventilation, here is an easy to use guide on Shock. The jpg is below and the pdf is also downloadable from our guides page. 

Feel free to use / print / spread.

Webucation 30/6/17

Webucation this month comes from the realms of trauma, cardiology. paeds and tests our "mythos" on cardiac arrest management! All credit to the original content providers.

• Pressing those veins
• Is Amiodarone dead?
• Ultrasound in paediatric trauma
• Egg white for sepsis?
• REACTing to REACT2
• The bamboo flute chest drain technique

• Is "A" really top of the treatment list?

The last link should make you wonder - are you really doing the right thing? LMAs that are inserted by ambulance personnel in the Singapore system are more than adequate. 

So things to focus on include:

• High quality CPR
• Reducing the over-oxygenation
• Using ETCO2 and U/S to guide your resuscitation
• Engaging reperfusion strategies early
• Replacing the tube when pendulum of stability has swung your way.

It's time to relook Sepsis

It’s 2017 and what has happened in sepsis care? This year, PRISM was done; no surprise given the 3 big guns last year (ProCESS, ARISE, ProMISe). Vitamin C may be the next big thing, and we are still trying to wrap our heads around which to follow – SIRS or SOFA.

Feel lost? Get up to speed with the following write-ups…

• Definitions and Identification of Sepsis: Sepsis 2.0 vs Sepsis 3.0
• Practical Evidence Podcast 015 – Surviving Sepsis Campaign (SSC) Guidelines 2016 (in 2017)
• Six myths promoted by the new surviving sepsis guidelines
• iSepsis- Clinical Features and Diagnosis
• Are we getting cosy on the septic SOFA?

And of course, vitamin C

• The Marik Protocol: Have We Found a “Cure” for Severe Sepsis and Septic Shock?
• Could vitamin C save lives in sepsis? These hospitals aren’t waiting for proof.
• Vitamin SCepTiC?
• Metabolic sepsis resuscitation: the evidence behind Vitamin C

Infuse > push

We always love a ketamine article here so no surprise we're infusing rather than "pushing" this one. Thanks to Journalwatch for this review.

Low-Dose Ketamine for Pain: IV Push or Slow Infusion? Daniel J. Pallin, MD, MPH Reviewing Motov S et al., Am J Emerg Med 2017 Mar 3; Neuropsychiatric side effects were more common with intravenous push administration, but does it matter?

At intravenous (IV) doses of 0.1–0.3 mg/kg, ketamine is a safe and effective analgesic. Adverse effects are minimal and include sedation and a feeling of disconnection from reality. Investigators compared the effectiveness and adverse effect burden of ketamine administration by IV push versus slow infusion in a randomized, placebo-controlled, double-dummy trial. Forty-eight emergency department patients with acute pain received 0.3 mg/kg of IV ketamine given either over 5 minutes by push or over 15 minutes by infusion. Feelings of unreality (quantified using the Side Effects Rating Scale for Dissociative Anesthetics) were more common in the IV push group overall (92% vs. 54%). Sedation was more pronounced in the IV push group, with median Richmond Agitation-Sedation Scale values at 5 minutes of −2 versus 0. The groups were comparable in terms of analgesic efficacy, but feelings of unreality were more pronounced in the IV push route at all time points. Comment This well-conducted study suggests that analgesic-dose ketamine causes less dissociation and sedation when infused over 15 minutes than when pushed over 5 minutes.

Webucation 28/2/17

This shot of Webucation includes sonography, pulmonary physiology, old school physics and even some etiquette advice. All credit to the original content providers.

• Hocus POCUS in cardiac arrest
• Things that scare me
• "Back to school" mathematics on closing velocity
• Impact of rudeness on medical teams
• Doctors better than Google?

• The truth about oximetry

The last link is extols a personal bug bear as well - why stab someone's artery to prove nothing? So in the future think twice before an ABG.

Surviving sepsis 2017

Great update on sepsis by JournalWatch. For those who do not have access:

Surviving Sepsis Campaign Updates Guidelines for Management of Sepsis and Septic Shock Daniel M. Lindberg, MD Reviewing Rhodes A et al., Intensive Care Med 2017 Jan 18; This revision of the 2012 guidelines focuses on early management in adults.

Sponsoring Organizations: Surviving Sepsis Campaign, Society of Critical Care Medicine, and European Society of Intensive Care Medicine Target Population: Clinicians who care for adult patients with sepsis and septic shock in a hospital setting. Background and Objective Sepsis remains incompletely understood, imperfectly defined, underrecognized, and exceptionally lethal. The Surviving Sepsis Campaign convened 55 experts from 25 organizations to undertake a systematic review and grading of evidence to update guidelines for the management of sepsis and septic shock in adult patients (NEJM JW Emerg Med Apr 2013 and Crit Care Med 2013; 41:580). This revision was conducted before publication of the Sepsis-3 definitions and does not incorporate them (NEJM JW Gen Med Mar 15 2016 and JAMA 2016 Feb 23; 315:801). Key Recommendations Patients with hypoperfusion should receive at least 30 mL/kg of IV crystalloid within 3 hours (strong recommendation, low quality of evidence), and should be re-assessed frequently (best practice statement). For patients who require vasopressors, the initial target mean arterial pressure should be 65 mm Hg (strong recommendation, moderate quality of evidence). IV antibiotics should be started within 1 hour of sepsis recognition (strong recommendation, moderate quality of evidence), and should include combination therapy (at least two classes of antibiotics to cover a known or suspected pathogen) for patients with septic shock. Combination therapy should not routinely be used for patients without shock. Norepinephrine is the first choice for patients who need vasopressors. Vasopressin or epinephrine can be added. For patients who remain unstable, dobutamine is recommended. IV hydrocortisone (200 mg/day) is suggested for patients who are hemodynamically unstable despite fluids and vasopressors. Blood transfusion should be reserved for patients with hemoglobin concentration <7.0 g/dL, except in special circumstances such as hemorrhage and myocardial ischemia (strong recommendation, high quality of evidence). Platelets should be given if the platelet count is <10,000/mm3 or <20,000/mm3 with bleeding. Sodium bicarbonate should not be used for most patients with pH ≥7.15. What's Changed With publication of the PROCESS and ARISE trials, these guidelines de-emphasize protocolization of care and invasive monitoring, instead suggesting that patients be re-evaluated frequently. Comment We continue to search for new definitions, diagnostic tests, antimicrobials, and treatments for patients with sepsis. However, improving outcomes probably has as much to do with increasing adherence to the practices we already know are effective and embedding automated passive alerting functions in the electronic medical record. For patients with sepsis, provide early, aggressive treatment with fluids and antibiotics, coupled with frequent re-assessment. CITATION(S): Rhodes A et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017 Jan 18; [e-pub]. (http://dx.doi.org/10.1007/s00134-017-4683-6)

CT after CA... worth it?

Here's a good nugget of food for thought from Medscape. We do this too. Outcomes are yet to be viewed though.

SUMMARY AND COMMENT | EMERGENCY MEDICINE January 13, 2017 Early Head CT After Cardiac Arrest: One Center's Experience Daniel M. Lindberg, MD Reviewing Reynolds AS et al., Resuscitation 2017 Jan 3; Many computed tomography scans showed abnormalities in this retrospective study, but it's not clear that performing early head CT improved care.

Neurological emergencies can result in cardiac arrest, and neurological injury can occur as a result of cardiac arrest. These authors retrospectively assessed the utility of head computed tomography (CT) in patients with out-of-hospital cardiac arrest who survived for at least 24 hours at a single academic center from 2007 to 2015. Of 213 patients in the analysis, 115 (54%) underwent head CT within 24 hours. In 43 patients (20% of all patients; 37% of those who underwent head CT), head CT showed abnormalities, such as loss of gray-white differentiation, global cerebral edema, and ischemic stroke. The authors note that head CT findings led to changes in management in 15 patients. These changes included transfer to the neurological intensive care unit, repeat head CT, and neurosurgical consultation alone; only one patient underwent neurological surgery. Of patients for whom CT findings changed management, only one survived, in a persistent vegetative state. Comment The limited clinical significance of the CT findings and of the resulting management changes does not make a compelling case to expand the use of CT scans. In patients stable enough for imaging, head CT should be obtained if pre-arrest symptoms or the neurological exam suggest a neurological source for the arrest or if the patient had significant head trauma.