EMCrit/Sinai ED Critical Care Conference Recap

ED Critical Care Conference

Today was the 9th annual ED critical care conference hosted at the Mount Sinai Icahn School of Medicine and the emDocs crew was there. This conference is described as “the largest free Emergency Critical Care conference in the country,” and featured speakers this year included Rich Levitan, Haney Mallemat, and Scott Weingart on subjects ranging from “epiglottoscopy” and crics to vent troubleshooting and pulmonary ultrasound. There was a segment on anti-coagulation reversal, and a debate (cage match?) between Andy Jagoda and Anand Swaminathan over the utility of alteplase in ischemic stroke before the day concluded with a resident BLAST competition.

Go brew some coffee for this one – it’s a long recap, but only because there was so much to learn.

Dr. Rich Levitan

The conference was widely tweeted with the hashtag #emcritconf, and Dr. Levitan kicked it off with a couple of useful mnemonics stressing the importance of the often underutilized technique of nasal oxygenation.

NODESAT and OOPS

He described the nose as the “neglected orifice” in patients “dying of hypoxemia,” and mentioned the application of high-flow nasal cannula and a facemask as one of his first steps in approaching patients in respiratory distress. He also imparted some advice for laryngoscopic technique, with a key component being the early identification of the epiglottis:slow down and find the epiglottis!He was asked at one point whether residents should be using more video or direct laryngoscopy, and he stated that while he felt the skill sets were interchangeable to a degree, he expressed a strong preference to not “give up the skill set of DL.” In the future, he expects the standard to become video-augmented DL, and having a future generation of physicians only comfortable with video laryngoscopy will likely lead to significant difficulty with some airways. Regardless of the modality used though, its all about “epiglottoscopy.”

Cric to Cure

Dr. Levitan also described technique for surgical airways, but didn’t neglect to mention the gorilla in the room – namely, the intimidation factor of this particular procedure. He stated it is absolutely crucial to both recognize the “surgically inevitable airway” and to not take the path of “delay and avoidance” that will invariably lead to bad outcomes in these patients.

limitations to cricHe described the three major barriers to performing a cric being technical skill, anatomical insight, and the requisite “mental armor.” He went into detail on the use of the “laryngeal handshake,” starting high and wide using all 5 fingers to palpate the hyoid-thyroid-cricoid complex (rather than just your index finger) in order to find the cricothyroid membrane. This technique is especially helpful in patients with less prominent thyroid cartilage (ie, females).

Once you’ve find the right space, confidence in making your incision comes through an understanding of the “cartilaginous cage,” which essentially provides nearly circumferential protection around the cricoid membrane (with thyroid cartilage laterally and the high back wall of the cricoid cartilage posteriorly).  He also recommended positioning yourself with your dominant (cutting) hand anchored on the patient’s sternum.

cric technique

Dr. Haney Mallemat

“Hero to Zero”

Dr. Mallemat began by describing the great feeling you have after successfully intubating a patient, only to have it replaced with total deflation when you discover that his or her respiratory status is still in jeopardy. In this talk, he offered some methods for systematic troubleshooting, namely, “DOPES like DOTTS.”

“DOPES” helps you diagnose the problem.

dopes

Displaced tube/cuff
Start by checking the depth of the tube (cm at teeth/lips)
Obstruction
From a mucus plug, for example, or if the patient biting down secondary to inadequate sedation
Pneumothorax
Can result from a bleb, overaggressive bagging, CVL placement, or ventilator-induced lung injury (VILI)
Equipment Failure
Look at all of the connections from the tube to the ventilator and ensure there is no disconnection or kinking
Stacking
AKA auto-peep. Essentially this is the ventilator giving the patient a breath before they have fully exhaled. Seen in patients with COPD/asthma, overly aggressive bagging or vent rate, and air hunger (ie, patient-triggered). Stacking has hemodynamic implications as well – it can increase intrathoracic pressure and subsequently decrease venous return to the heart (preload) as well as increase the afterload seen by the RV.
stacking

“DOTTS” will then help you to fix the problem.

Disconnect the Tube
Sometimes you can hear a hiss of air as the extra volume is released. You can additionally put light pressure on the chest to help the patient exhale.
Oxygen
Provide 100% O2 and bag the patient. This will give you the time you need to take a step back and assess the situation. Check the ETT position at the lips if you haven’t already, check for chest rise as you bag, listen for an air leak, listen for bilateral breath sounds, examine time required for full expiration, feel for crepitus, and feel for lung compliance as you bag.
Tube Position/Function
Attempt to pass a bougie or suction catheter all the way through the tube, or just re-sedate the patient and take a look with DL.
Tweak the Vent
Check the waveform for breath stacking, ie, the volume delivered by the vent is more than the volume returned by the patient. Try decreasing the tidal volume first, then try to decrease the respiratory rate to increase expiratory time. Additionally, you can increase the flow rate to decrease inspiratory time (and conversely increase expiratory time). Dr. Mallemat stressed that you should know how to do these things your self (the idea of “owning” your department), and not have to rely entirely on the respiratory therapist.
tweak the vent
There are groups of patients in whom decreasing the tidal volume and respiratory rate may be more likely to harm than help. You do risk causing a degree of hypercapnea and respiratory acidosis, which should be OK in most cases, unless: 1) The patient has increased ICP, which hypercapnea will exacerbate through vasodilation. 2) The patient has a toxic ingestion and can’t sustain any additional acidosis.
Sonography at the Bedside
Can be helpful in identifying the presence of a pneumothorax.

Essentially, the message is to “Keep Calm and Be Systematic.”

  1. Put the patient on 100% oxygen and just look at them to start – are they bucking, biting, or disconnected?
  2. Obtain some history. Who intubated the patient? Were there any complications? What meds did they get? What procedures (if any) have been done?
  3. Perform a pertinent physical exam. Are the vitals stable? Does the patient appear to be in pain or are they agitated? Look, listen, and feel (as above).
  4. Check the vent’s waveform. Air hunger classically presents with a scallop-shaped waveform, which can be addressed by increasing the tidal volume or adjusting the flow rate to give the patient the sensation of a fuller breath. If the waveform appears more like breath stacking, consider the etiology of this (sedation issue?), and decrease the tidal volume, respiratory rate, and/or i-time (as mentioned above).
  5. Check labs & imaging. Check sats & EtCO2, an ABG/VBG, and use an ultrasound!
  6. Evaluate the patient’s respiratory mechanics. Determining the degree of resistance and compliance will point you in the right direction. We often hear about the peak pressure being too high, but what you should ask is what the plateau pressure is (and keep the level under 30). If peak pressure = plateau pressure, there may be a compliance issue resulting from overload, ARDS, or a neuromuscular etiology. If peak pressure is greater than plateau pressure, instead think about resistance (copd/asthma, mucus plug).

plateau & peak pressuresThe caveat for these six steps is that the patient must be calm and comfortable for the checks to be accurate, and the physiology described is really a gross oversimplification (but should be enough to help narrow down the problem).

Why Think When You Can Look?

Dr. Mallemat’s second talk was on the use of ultrasound for airway and lung exams. If you think you hear crackles on your exam, why not grab the ultrasound and look for yourself?

Ultrasound for Airway
He explained how you can use the linear probe on the lateral neck to visualize the esophagus (muscular appearing, and lateral to the trachea) during intubation. If the tube passes and it suddenly looks like the patient has two tracheas, then you’ve just confirmed incorrect placement without even waiting for EtCO2.
Ultrasound for Surgical Airway
For those “#WTF?” airways, in which palpating landmarks is just not going to be possible. With the probe, you can at least find these landmarks and then mark the neck with a pen.
Ultrasound for Evaluating Dyspnea
This is helpful when an XR is inconclusive and getting a CT isn’t feasible. With a phased array (curvilinear) probe, you can assess for presence of edema (b-lines/comet tails), effusion (can look simple vs. complicated/heterogeneous to suggest transudative vs. exudative process), hepatization (airless lung, suggesting compression from without or obstruction from within), or collapse (seashore/barcode sign) of the lung.An exam for dyspnea wouldn’t be complete without performing a quick echo to look for pericardial effusions, RV collapse or hypokinesis, or checking the lower extremities to rule out a clot.

Dr. Scott Weingart

“A Logistical Approach to the Reversal of Anticoagulants”

Dr. Weingart mentioned that his lecture was available on emedhome.com (free for residents), as well as (in part) on emcrit.org. [emDocs plug: check out our recent writeup on the topic as well.]

He started with the case of a patient on warfarin with an intracranial hemorrhage, with the strategy for active bleeding being “Vitamin K plus something,” with that something preferably being PCC. FFP was discussed at length – it is a viable option and will work, although the concern is the volume required to reach the goal INR (FFP has an intrinsic INR of ~1.5).

How do you dose FFP? 15cc/kg. In terms of units, how many will you need to use? 1 unit replaces ~2.5% of factor, and at least 10% of factor needs to be repleted. Upwards of 8 or even 10 units may be required to be therapeutic, but you run into the risk of TACO (transfusion associated cardiac overload) from the sheer degree of volume you’re giving.

coumadin reversal with ffp

From a logistic perspective, he mentioned that there should be NO problem with blood banks thawing products (they will not be wasted if unused), and if you are anticipating the need, you should explicitly request the thawing of 8 units off the bat.

FFP is the “something else” of choice if the patient needs volume resuscitation in addition reversal. Otherwise, if its a small bleed in a specific area, then you should opt for just reversing them with PCC.

What about FVIIa (novo7)? It will improve the INR, although this is because INR is almost entirely factor VII dependent (it doesn’t measure II, IX, or X that are also inhibited by warfarin). As a result, you fix a single factor level and the INR improves, but the patient will continue bleeding – not the desired outcome.

PCC is the ideal choice, as it is fast and uses less volume. Three types are available – three factor, four factor, and FEIBA. The three factor includes II, IX, and X, so will not reverse the INR, although bleeding time does improve (Dr. Weingart mentioned he’ll be publishing data on this soon). You can add 2 units of FFP to this if needed to complete the reversal.

Four factor PCC (II, unactivated VII, IX, and X) will fix the INR and the bleeding. Known internationally as Beriplex and recently approved in the US with the name Kcentra. FEIBA is similar to four factor PCC, but its factor VII is already activated.

reversing coumadin with mechanical valve? yes!

If the patient has a mechanical valve, can you still reverse? Yes. The risk of clotting the valve is four per 100 patient-years, making the risk extremely low if you reverse the patient for one or two days (especially if the trade-off is an almost certain loss of brain).


He moved on to reversal of patients taking dabigatran, mentioning that no great treatments really exist. In terms of monitoring levels, a normal aPTT indicates the absence of a significant effect. If dabigatran has been taken within the previous 2 hours, activated charcoal can be given. FEIBA may help and is probably the best shot at this point, although has not been proven to help. Hemodialysis will help somewhat, although if the patient doesn’t have existing access, obtaining it could be a nightmare.

Lastly, he mentioned that patients on Xa inhibitors (-xabans) should be reversed with PCC (four factor, or three factor + FFP).

The talk finished with Dr. Weingart stressing that effectively reversing patients on these medications is all about taking care of the logistics – do you know where to get the reversal agents? Can you mix them? Do you know how much to give, and how to administer them? These are the elements of care that translate into a patient getting better.


Debate/Final Thoughts

Drs. Jagoda & Swaminathan debated the evidence for the use of alteplase in ischemic stroke (a class A recommendation), making no conciliations and reaching very little middle ground on the topic by the end, other than recommending that people read the literature and decide for themselves.

jagoda/swami debate


Overall a great day, and just an incredible panel of speakers. We’re grateful to Dr. Weingart & Mount Sinai for organizing the conference, and to everyone who was tweeting throughout and sharing the knowledge!

6 thoughts on “EMCrit/Sinai ED Critical Care Conference Recap”

  1. This is great review Baker! Agree with importance of getting down technique of surgical airway. I got a lot of practice just going through the technique 20 times at the 2013 Resus Conference in Vegas. Just going over the steps repeatedly (even on mannequins) helps create some form of muscle memory.

    1. Hey thanks Adaira. I’d like to give these another shot on cadavers or mannequins using the technique he was describing. Did you get to practice needle crics as well?

      One thing I didn’t mention above was Dr. Levitan’s expressed strong preference for open crics and general lack of faith in the melker percutaneous technique (in adult patients). The argument was basically that the latter works especially poorly when neck landmarks are distorted, the needle can get plugged up with skin or clot, and in his experience they tend to take longer to perform.

      Dr. Weingart debated needle vs. knife on one of his podcasts, and his website has a pretty great discussion of it as well: http://emcrit.org/podcasts/cricothyrotomy-needle-or-knife/

  2. Great summary.

    Small typo:

    Additionally, you can DECREASE the flow rate to decrease inspiratory time (and conversely increase expiratory time).

    The first decrease should be increase…

    Chris

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