11/1/2014. Just The. Pearls. Everything I do is Off-Label! This is the ultimate lecture for the ADHD emergency physician.

Transcription

1 Just The Everything I do is Off-Label! Pearls This is the ultimate lecture for the ADHD emergency physician. 1

2 >20 Tips in 60 Minutes You re repeatin yourself ½ Trauma ½ Medical Arrest Crit Care in The Trauma Bay Case 2

3 Hypotensive in the Field HR 96 BP 180/20 Sat 89% NC RR 22 GCS 14 (-1 Eyes) Moves Ext x 4 What do you think? Ignore HR Low or normal HRs are not on their own reassuring in sick trauma Resuscitation Sep;81(9):1142; Resuscitation 2011;82:556; J Trauma 2009;67:1051; BMJ 2004;328:451; J Accid Emerg Med 1995;12:1; J Am Coll Surg 2003;196:679; J Trauma 1998;45:534; J Trauma. 2011;71:

4 Ignore Initial Automated BPs Rep Time J Trauma. 2003;55: Don t believe the 1 st few BPs in sick trauma patients; check your rep So, if you can t trust the initial vitals ETCO 2 Low=Badness 4

5 <C>ABC Push on Belly Squeeze Pelvis Feel Feet Pelvis Moves Under Your Hands Bind It! 5

6 Better than ExFix Orthopods have nothing to offer the crashing trauma patient JACS 2007;204:935 Is Sheeting as Good? Can you Make Things Worse? Pelvic Binding: Early and 50/30 6

7 Cavities Mass Trans Airway Monitoring Cavities: Where s That Bleed Chest Intra-P Retro-P Thigh Street Chest Intra-P Retro-P Thigh Street Empiric Chest Tubes 7

8 Finger Thoracostomy 200 ml Blood on L Nothing on R CT on Left Chest Intra-P Retro-P Thigh Street FAST Liver Tip with Patient in Trendelenberg 8

9 When the FAST really matters, RUQ Liver tip with Trend. is the Chest Intra-P Retro-P Thigh Street Cavities Mass Trans Airway Monitoring Mass Trans: Hemostatic Resus 9

10 PRBC/ Clotting Factors 1:1 vs. 1:2 PROPPR Trial Type O PRBC Thawed AB Plasma Should be in the Trauma Bay Scores >4 Units in the 1 st Hour 10

11 LLS Score ABC Score TXA Early Cryo RoTEM/TEG Directed Care 11

12 The Rise of the Concentrates Fluid Choices in Sick Trauma Patients Warm Under Pressure Containing clotting factors or oxygen Calcium 12

13 90/50 after 2 PRBC 2 FFP Cavities Mass Trans Airway Monitoring MEDs: Rocur Ketamine onium Hypotensive intubation meds: high-dose roc, lowdose Cavities Mass Trans Airway Monitoring Femoral Arterial Line Shock 40(6), December 2013, p

14 Ultrasound CFA not the SFA Yes, it s ok in a pelvic fx MAP 48 Resus Goal? Permissive Hypotension? 14

15 Minimal Normotension MAP >= 65 and perfusing May be 50 very soon <65 give the fluid of trauma J Trauma 2011;70: vs 65 >65 eat away at the adrenals Fentanyl mcg J Trauma Jun;52(6):

16 At 1 mg pt is warm, perfusing & anesthetized What about TBI? Some would say SBP>90 We have a bedside test for Increased ICP Ocular ultrasound is a bedside test for ICP elevations in trauma 16

17 90/50 6 PRBC 4 FFP 1 Pack Plt 1 Pack Cryo Where should we go now? OR vs. IR We Shouldn t Have to Choose Resuscitation with Angiography, Percutaneous Techniques and Operative Repair Can J Surg. Oct 2011; 54(5): E3 E4. 17

18 RAPTOR: we should not have to choose between IR and 40/20 60/40 Bedside Intervention? REBOA 18

19 Resuscitative Endovascular Balloon Occlusion of the Aorta From Megan Brenner REBOA: vascular control without the big cut coming to a trauma center near 120/80 More fentanyl and to RAPTOR Suite for Angio 19

20 Review Low or normal HRs are not on their own reassuring in sick trauma Don t believe the 1 st few BPs in sick trauma patients; check your rep Pelvic Binding: Early and When the FAST really matters, RUQ Liver tip with Trend. is the Hypotensive intubation meds: high-dose roc, lowdose 20

21 Ocular ultrasound is a bedside test for ICP elevations in trauma RAPTOR: we should not have to choose between IR and REBOA: vascular control without the big cut coming to a trauma center near Cookbook 21

22 Nihilism ACLS Push hard & fast Truly Advanced Cardiac Life Support for Resuscitationi sts t 22

23 Max Harry Weil Airway Disease-a-Month 1997 Convert to Tube ASAP 23

24 Custom Bent Bonfils Fiberoptic Stylet Breathing Grossman On Combat Hook them to the Ventilator 24

25 Set Peak Pressure Limit to > 100 cm H 2 0 Set the rate low Circulation Quality Compressions What about depth? 25

26 Eliminate Peri-Shock Pause Look-Through Rhythm Analysis ROC Primed Resus 2014;85:336 Crit Care Med 2013;41:1782 LINC - JAMA. 2014;311(1):53-61 Sandra Ware on resus.me 26

27 STEMIs go to Lab; Even if Coding Drugs Circulation 2012;126(13):1605 Epi VSE The PACA Trial: Jacobs et al Resuscitation. 2011;82(9):1138 JAMA. 2013;310(3):270 Arch Intern Med 2009;169(1):15 Esmolol Nitroprusside? Emergency Department Use of Esmolol in Refractory Ventricular Fibrillation --Driver, Plummer, Smith Prolonged Adult Cardiac Arrest With Enhanced Cardiopulmonary Resuscitation and Sodium Nitroprusside Yannopoulos Group 27

28 Monitoring Femoral Arterial Line Epi Dosing by DBP Resuscitation 2013;84:696 Crit Care Med 2013;41:2698 JAMA 1990;263(8):1107 Resus 2014;85:350 28

29 20 RUSH Human Factors RUSH 29

30 Quiet ECPR Image from ep monthly Time to CPR and Premorbid State Matters Time Coding doesn t matter! 30

31 A time to CHEER Cookbook Cardiac Arrest Resuscitation by Resuscitationists 31

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