adeline.

I've been sayin it for years... well, close to a year now:

we need to stop teaching and expecting our medical students, junior doctors and 'real world' practicing doctors to be experts in critical appraisal of EBM, let the experts be experts in appraised EBM.  Instead, we need to teach our underlings (and ourselves) how to find that expert apprasial and take it to the bedside (knowledge translation).   Now it seems there is some evidence and other smart people who are thinking the same way:

learning information management not EBM

In reponse to all the recent online talk of DSI vs RSI and DL vs VL, I have modified my airway algorithm. Basically I'm not ready to give up on DL completely, and am an enthusiastic adopter of high flow nasal O2, which has already bailed me out of a few hairy situations. This is just a draft, and I'm looking for feedback... Check out the links below for the background material out in the ED ether

http://prehospitalmed.com/2013/01/26/delayed-sequence-intubation-or-dci-deadly-critical-intubation-nope-that-doesnt-sound-better/ 

http://i1.wp.com/emcrit.org/wp-content/uploads/2013/02/VortexCognitiveAid.png

 http://mdaware.blogspot.com.au/2013/03/rsa-ok.html

 http://emcrit.org/podcasts/emcrit-intubation-checklist/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+emcrit+%28EMCrit+Blog+-+Emergency+Critical+Care%29&utm_content=Google+Reader

 http://prehospitalmed.com/2013/04/19/if-you-had-45-minutes-could-you-intubate-anyone/

FOAM and Fellowship study intersect…

studying for fellowship, found the previous SAQ below:

1. Discuss the evidence regarding the use of Oxygen therapy in the Emergency

Department in relation to the following presentations. (100%)

a. Acute coronary syndromes

b. Acute exacerbations of chronic airways limitation (cf. CAL / COPD)

what the what???  I found this one rather difficult until I serendipitously came across these FOAM posts below

RESUS.me

Scancrit.org

underneathem.org

UMEM educational pearls

emergencyeducation.net.

ANSWER:

discuss = pro/con, list

Key Issues:

• oxygen therapy is cornerstone of treatment modality in critically unwell patient
• not evidence based
• essesntial in hypoxic patients (O2 sat<90%) and in cardiac arrest, Pre-ox for RSI, sepsis, shock, trauma, near-drowning, CO poisoning
• evidence suggest ‘supra-normal’ levels detrimental
• best practice is to titrate oxygen therapy to a peripheral 02 saturations between 88-94%

oxygen in ACS:

pro:

• vital in hypoxic patient to ensure optimal oxygen delivery to tissue, namely: myocardium,
• simple to apply,
• cheap,
• recently defined as standard of care

con:

• emerging evidence suggests supra-normal levels of oxygenation has potential harm in not only ACS, but neonatal resuscitation, COPD, post cardiac arrest, Stoke, TBI, and ARDS.
• Namely through production of toxic free radicals, excessive oxidative stress to reperfused tissues, widespread vasoconstriction of coronary and cerebral vessels, and associated increase SVR, potential increase V/Q mismatch
• most recent AHA/ACC guidelines de-empasize High-flow use of oxygen in uncomplicated MI/ACS patients, suggesting rather a titrated dosage, aiming for FiO2~40%

**might be even more clever to comment that more answers to come with the publication of the AVOID trial (A randomized controlled trial of oxygen therapy in acute myocardial infarction Air Verses Oxygen In myocarDial infarction)

Oxygen in COPD

Pro:

• vital in the critically hypoxic patient 
• simple to apply 
• cheap  
• ubiquitous in all facets of health care provision 

con:

• patients prone to retain CO2 due to Chronic airway limited disease processes have reset central chemoreceptors that normally stimulate breathing in response to dec. pH/inc CO2, this results in reliance on peripheral receptors responding to hypoxic to stimulate respiration.  high arterial O2=no stimulus to breath=continued rise in CO2=acidosis,deterorating LOC. 
• similar to systemic effects described for ACS: oxidative stress, free radicals, vasoconstriction, V/Q mismatch. 

 **I assume buffing this part of the answer with a comment on a recent Hobart pre-hospital study showing increased mortality in COPD patient receiving high flow O2 is going to make you look good.

Boo-yah!!  nailed it,  NO Cameron/tintinalli/Dunn needed, thank you very much. VIVA la FOAMed….

PS: I would like to see what an answer like that would score… I pointing at you Mark  and recent fellowshites!  as well as anyone else who might have some good suggestions for a better answer: I found it very diffcult to come up with ‘pros’  seems obvious doesn’t, anybody have others?

Heard this one before? This is one of the many bizarre paradigms I have heard whispered around some places, and it's teaching people bad habits.

So here are the myths about oxygen dispelled. My own Oxygen Physiology for Dumbasses.

Oxygen Physiology PDF 

Check out this 45 minute lecture by Mike Stone of US podcast fame.

Enjoy

http://vimeo.com/31010728

fast-forward to the 32 minute mark and watch the next 15min...pure inspiration

hell, watch the whole program. amazing....

basics in head trauma:

• let gravity help with pressure (head of bed up, no constricting noose around neck to obstruct venous flow i.e. collar, ETT tape)
• shut their brain off (dec. metabolic demand)
• keep enough Blood to the brain (CPP = MAP-ICP)  ; need a MAP >80, this may be a caution with propofol
• keep everything in blood normal:CO2,BSL,O2,temperature.

I cant find anywhere to suggest inc. in ICP
http://lifeinthefastlane.com/book/critical-care-drugs/propofol/

some protocols favor it in traumatic head injury
http://emcrit.org/podcasts/high-icp-herniation/

in reality, it does not matter what sedative you use, just use something as that is defnitely know to worsen ICP and outcomes 
http://resus.me/sedation-for-traumatic-brain-injury/
http://www.ncbi.nlm.nih.gov/pubmed/22094498

Anyone disagree?

scott

Busy times at the ol’ Maitland ED this past weekend, unsuspecting adolescent head traumas, old guys with septic shoulders, uncontrollable hepatic encephalopathies, rugby players with neck fractures and neurologic deficits and, a 2yo with mid-shaft fractured femur…   lots of FOAMy goodness here, lots I could report on how the use of blogs, podcasts, and social media helped us manage the madness.  After re-telling the stories of the weekend to a few sorry souls who had to listen, I was a little taken aback by the quizzical looks, follow up questions, and interest in how to do femoral nerve blocks for the acute treatment of mid-shaft femur fractures, even in 2yo’s. So, topic picked!

Disclaimer: not here to re-invent the wheel, only direct you to the online resources that have.

Femoral nerve blocks work:

http://journals.lww.com/pec-online/Abstract/2012/02000/Ultrasound_Guided_Femoral_Nerve_Block_for_Pain.21.aspx

http://www.annemergmed.com/article/S0196-0644(06)02261-X/abstract

even the orthopaedic guys think so:

http://jbjs.org/article.aspx?articleid=27863

it is easy to learn online:

http://www.neuraxiom.com/html/newfemoral.html

http://www.neuraxiom.com/html/ficb.html

Silly not to do it with USS

http://www.ultrasoundpodcast.com/2012/03/episode-24-femoral-nerve/

http://www.ultrasoundvillage.com/imagelibrary/cases/?id=121&media=456&testyourself=0

http://www.sonoguide.com/femoral_nerve_block.html

great tip on dosing: 

mix up a 50:50 solution of 1% lidocaine with 0.5% bupivacaine and, before ultrasound guidance, used 1mL per year of age. It works out as less than 2mg/kg of lidocaine (usually) and less than 1mg/kg bupivacaine

http://stemlynsblog.org/2012/07/through-the-looking-glass-chirocaine-vs-bupivicaine/

its in our exams;

http://lifeinthefastlane.com/2009/11/quiz-paediatrics-013/

bottom line, just learn to do it, your patients will thank you.

scott