FOAM A New Style of Learning for a New Generation. Eric Einstein, M.D. Henry Ford Hospital Department of Emergency Medicine November 13, 2014

Transcription

1 FOAM A New Style of Learning for a New Generation Eric Einstein, M.D. Henry Ford Hospital Department of Emergency Medicine November 13, 2014

2 Objectives Define and discuss the basics Peer review a podcast Discuss different sources of information/education Draw some conclusions

3 If you want to know how we practiced medicine 5 years ago, read a textbook. If you want to know how we practiced medicine 2 years ago, read a journal. If you want to know how we practice medicine now, go to a (good) conference. If you want to know how we will practice medicine in the future, listen in the hallways and use FOAM

4 FOAM Free Open Access Meducation FOAMed Technology Modalities, availability Timely, instantly critiqued EM RAP, EMCrit, ALiEM, LitFL, EMDOCS.com

5 EMCrit

6 The Laryngoscope as a Murder Weapon HOP

7 Hemodynamics Kill! Hypotension is the biggest predictor of perintubation copmlications/mortality

8 Schwartz, Matthay M, Cohen N. Death and other complications of emergency airway management in critically ill adults: a prospective investigation of 297 tracheal intubations. Anesthesiology [Internet] intubations in ICU 7 deaths during or within procedure, 5/7 a/w hypotension, 4/5 on pressors Mortality associated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation

9 Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. Journal of critical care; 2012;27(4):417.e9-13 Retrospective cohort study in large urban setting NOT hypotensive 30 minutes prior to ETT 336 pts, 79 (23%) went hypotensive. Patients with PIH had significantly higher in hospital mortality (33% vs 21%) and longer ICU LOS (9.7 vs 5.9 days) and hospital LOS (17.0 vs 11.4 days)

10 Hemodynamics Kill ALL induction agents will drop BP in shock patients Sedation and catecholamine surge

11 NON

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13 Anesthesia & Analgesia: Cardiovascular Anesthesia: Research Report Predictors of Hypotension After Induction of General Anesthesia Reich, David L. MD Computerized anesthesia records of 4096 patients undergoing general anesthesia Pre induction hypotension independent risk factor for post induction worsening hypotension (OR 5) Used etomidate, fent/versed, propofol, thiopentate

14 Etomidate

15 Benson M, Junger. Use of an anesthesia information management system (AIMS) to evaluate the physiologic effects of hypnotic agents used to induce anesthesia. Journal of clinical monitoring, Patients in OR, measured ABP at 5, 10, 15 mins Etomidate drop in bp 17-23/ (11-13) Not in ED, patients not in shock

16 Zed P, Laban R. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Academic emergency medicine 491 Patients INCREASE in HR and BP (including those with SBP < 100)

17 Smith DC, et al. A trial of etomidate for rapid sequence intubation in the emergency department. J Emergency Med 2000;18:13-16 Prospective, observational study Hemodynamic monitoring for 6 minutes after induction mean change in systolic and diastolic blood pressure of 1 ± 39 mmhg and 0 ± 28 Hypotensive patients (< 80) mean decrease of 6%

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19 Ketamine His favorite gives sympathetic surge Teaching 2-3 mg/kg I use in between pain and sedative dose (0.2 1 mg/kg) Not fully dissociated, don t lose endogenous surge NO EVIDENCE FOR THIS

20 Sequential cardiorespiratory patterns of anesthetic induction with ketamine in critically ill patients. LIPPMANN, M 22 critically ill patients got a-lines and PA lines Critically ill? BP? Resuscitated? Pressors? CO, BP, arterial and mixed venous gases, sats, ph, and Hct monitored over 15 minutes early progressive increase in HR, CI, BP (MAP), stroke work, and O2 delivery; O2 consumption (Vo2) and O2 extraction decreased Ketamine generally produced inotropic response, but not uniformly

21 Waxman K. Cardiovascular Effects of Anesthetic Induction with Ketamine. Anesthesia & Analgesia, critically ill patients undergoing surgery Half maintained or had increase in MAP, half decreased (with 2 below 60) 8/12 maintained or increased CI, 4 decreased SVR up in 6, down in 6

22 Waxman, Cardiovascular effects of Ketamine Doesn t define critically ill On pressors? Resuscitated? SBP (only MAP)? No one preinduction with MAP < 65 66) Dose range from mg Measurement at 5 minutes without intubation

23 Paralytics Paralytics take longer to work in shock state Muscles = peripheral circulation decreased perfusion Give a bigger dose

24 Changes in onset time of rocuronium in patients pretreated with ephedrine and esmolol--the role of cardiac output. Ezri T. Anesth Scand. Patients given ephedrine, esmolol, or nothing CO Ephedrine 52 sec Esmolol 114 sec Control 87 sec

25 Scopolamine Pretreat with 0.4 mg IVP Amnesia, increase HR (for increase CO) NO CITATIONS/EVIDENCE

26 Intubating the Shock Patient If time, resuscitate first, start pressors if possible or have them hanging Have push dose pressors ready Scopolamine 0.4 IVP pretreatment Ketamine mg/kg No evidence for lower dose Sux 2 mg/kg or Roc 1.6 mg/kg No evidence for higher dose

27 The Gold Standard Journals May come out years after start of research Bias Peer review not that great, not transparent Once it s published, not a lot of post publication review

28 Peters D, Ceci S. Peer-review practices of psychological journals: the fate of submitted articles, submitted again. Behav Brain Sci 1982;5: studies from prestigious institutions that had already been published Retyped the papers, made minor changes to the titles, abstracts, and introductions but changed the authors' names and institutions (Tri-Valley Center for Human Potential) Resubmitted to the SAME journals

29 Peters D, Ceci S. Peer-review practices of psychological journals: the fate of submitted articles, submitted again. Behav Brain Sci 1982;5: Only 3 of 12 were realized to be papers that had already been published 8 of remaining 9 rejected poor quality, not lack of originality Bias based on institution

30 Gøtzsche, P. Adequacy of authors replies to criticism raised in electronic letters to the editor: cohort study BMJ 2010; 341 Objective: Investigate whether substantive criticism in electronic letters to the editor, defined as a problem that could invalidate the research or reduce its reliability, is adequately addressed by the authors. Claims raised against 105 Only 47 responses

31 FOAM NOT scientific research Rather a way to dissect, discuss, deliberate the products of research Explore issues where research findings do not apply or exist An editorial or commentary The anvil of truth

32 The Benefits of FOAM It s FOAM Instant critique and peer review from the moment it comes out People and places

33 The Benefits of FOAM Instant critique and discussion of research TTM The new arena for presenting your research before it s published DSI, Apneic Oxygenation

34 But remember Know your sources Review the evidence PARTICIPATE!

35 The Future of FOAM A new forum for submitting research and peer review An adjunct to traditional learning styles for students and physicians at ALL levels FOAM Club?