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Kane Guthrie packs all the Free Open Access Meducation highlights from the past year as he can into 30 minutes.
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FOAM in Review Kane Guthrie
FOAM from 2012• The review:– 189 different EMCC blogs & podcasts
Crowdsourcing
The Big FOAMed Hit’s
Of 2012
The Popular OnesEMCrit DSI Best use of the Bougie
Thought Provokers
& Game Changers!
LMA in Cardiac Arrest • Does the LMA decrease cerebral blood
flow?
• Using FOAMed to challenge the science!
http://bit.ly/XGYcv9
LMA in Cardiac Arrest • They didn’t buy it!• Used MRI to show LMA doesn’t impede
flow!• Short paper response - rejected to
letter form• So they used FOAMed instead!– Blog post, videocast & podcast discussion!
http://bit.ly/XGYcv9
The Man who made Sepsis
NYC STOP Sepsis Collaborative
Sepsis in the EDLessons:– Time sensitive disease - High mortality– Needs early recognition– AB’s & fluids within 1 hour– Use lactate to find the cryptic cases– Non invasive approach is effective
http://emcrit.org/severe-sepsis-resources/
Ketamine or KetaMinh
Who’s using it more because of Minh?
Ketamine or KetaMinh• What is it good for?– Agitation/Aggression/Analgesia– Procedural sedation – Antidepressant– Hypotensive patients– Chronic pain – The DSI approach
PCAs in the ED• Review of 2 studies!• Provide less-labor intensive analgesia• Better pain scores• Few more adverse events!– Nausea, vomiting, pruritis
• Worth it in some painful conditions!
Critical Care Palliation
“When we can’t be aggressive with our resuscitation – we need to be aggressive with our palliation!”
http://emcrit.org/podcasts/critical-care-palliation/
Critical Care Palliation
3 things never to say:
• “Do you want us to do everything?”• “Do you want us to resuscitate her?”• “I am so sorry, there is nothing more
we can do”
http://emcrit.org/podcasts/critical-care-palliation/
Tranexamic AcidThe FOAMed world ask why we aren’t
using it?
– Its cheap! – Its an old drug!– But it works!– ?prehospital drug
Pressure Poisoning
• Lung protective ventilation – Meta Analysis
• Not just in ARDS!• Lower tidal volumes = better outcomes
Pressure PoisoningStart with:• 6-8ml/kg by IBW for all intubated ED
patients
And protect those lungs!
Hypoxic Patient?
Needs lots of O2?
Not for Intubation?
What to do?
High Flow Nasal O2
http://emupdates.com/2012/03/01/the-high-flow-nasal-cannula-in-the-emergency-department/
• Give ^60L/02/min• Enable 100% 02, with 5/
PEEP• Humidified• Great for NFI pts• More comfortable NIV• Use for DSI!
PPI & Upper GI Bleeder!• Face validity of using PPI’s• 750 million per/yr USA
• Systematic R/V -Cochrane• 2000 Pts
http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/
PPI & the Upper GI Bleeder!No difference in:• Mortality, rebleeding, need for
surgery!
http://thesgem.com/2012/12/sgem-16-ho-ho-hold-the-ppi/
The Best Tricks of the Trade!
Difficulty feeding the NGT tube?• Try the SCANCRIT manoeuvre!
http://www.scancrit.com/2012/05/30/scancrit-manoeuvre/
Opioid Induced Constipation = Naloxone
• Give 2mg Naloxone PO• Mix with lactulose/colonlytely• Doesn’t induce opioid withdrawal!
http://blog.ercast.org/2012/02/the-constipation-manifesto/
=
Superglue for CVCs• Need to secure that ART line or CVC
during a resus?Forget this: Try this:
http://bit.ly/Sf1sXY
Need to Chemically Cardiovert SVT?
Combine Adenosine with the • Use 20ml syringe• Draw up adenosine & flush together• Administer by fast IV push• Doesn’t reduce effectiveness!
http://academiclifeinem.blogspot.com.au/2012/12/trick-of-trade-combine-adenosine-and.html
Nebulised Naloxone • Worried about acute withdrawal with IV
naloxone?• Still got some respiratory effort?• Feel you need to do something?• Gives “gentle & effective” reversal?
Try 2mg naloxone, 3mls saline in a neb!
http://www.thepoisonreview.com/2013/02/01/nebulized-naloxone-in-opiate-intoxication/
Stabilising Mandibular Fractures
• Splinting mandibular dislocation/fracture
• Easy as
• Putting them in a stiff neck collar!
http://academiclifeinem.blogspot.com.au/2012/05/trick-of-trade-stabilizing-mandibular.html
A Dose of Dex• Casey been doing it for a while!• Cochrane then decided to agree with
him:Benefits: • Reduction of pain• Early onset - 24hours• Same Kids vs Adults• No difference Bact vs Viral
http://broomedocs.com/2012/12/a-dose-of-dex/
Ruling & Managing the
RESUS ROOM
Life, Limb & Sight SavingProcedures
• Published in emj & Resus.Me• Questions if we’re ready to perform:– Time Critical Interventions
Highlights metacompetence:• Ability to apply the intervention @ the right
time!http://resusme.em.extrememember.com/?p=6707
The Usual State of Readiness• Being ready to act with life-saving
maneuvers• Managing your own catecholamine's
Being ready • Cognitively• Materially
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
The Usual State of Readiness1.Cognitively• Invisible simulation • Develop & prepare plans/scenarios in
your mind!• Knowing what you need to know
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
The Usual State of Readiness2. Materially • Equipment you need• When you need it• Where you need it
• Checking your equipment yourself!
http://emupdates.com/2012/09/26/the-usual-state-of-readiness/
Mind of the Resuscitationist• Being at the sharpest end of EM• Making things happen• Controlling your environment• Science of human persuasion • Standing like a leader
Owning the Airway in 2012Been dominated by:
• From DL to VL• To Human Factors & CRM• & Tools and Techniques• Then LMAs, retrogrades, bougies, & airway
aids –all through to the surgical airway!
The Vortex
Changing the way we approach the difficult airway
The Vortex• “High stakes cognitive aid”– Simple enough to be recalled– Flexible enough to be use in any context
• Train staff in unanticipated difficult airway
• Using single, simple, universally applicable template
http://www.vortexapproach.com/Vortex_Approach/Vortex.html
The FOAM Checklists
EMCrit Intubation
EM Updates Intubation
EMCrit Post-Intubation
EM Updates Asthma
In SummaryFOAMed in 2012 was all about:• Airway management/devices• Teaching us to use Checklist• How to Rule the Resus Room
FOAMed showing how to practice medicine in the future!
Questions
Thank-you
May the FOAM be with you!
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