SMACCGold 2014 – The Northern Round-up
Five Northern Health Emergency Physicians and two nursing staff ventured to the second
Social Media and Critical Care Conference this March.
This year’s conference was even bigger and more spectacular than Sydney 2013 with a very
strong line-up of presenters mostly from Australasia, USA and the UK.
The strong focus on resuscitation and airway management continued but was matched by
significant discussions devoted to the less technical but equally critical social aspects such as
communication, teamwork, and education.
Dean Pritchard and Morgan Carlyon participated in the conference finale SIMWars and
acquitted themselves extremely well despite being confronted with an exsanguinating
Jehova’s Witness SIMMom andno access to an Obstetric team in front of a bank of cameras
and 1000+ people. Amazing effort.
All the talks can be accessed via the SMACCGold website and links from there to the many
other affiliated blogs/ websites.
More specific notes from some of the Northern Delgates are as follows:
Cynthia Lim:
Had a big airway week attending Richard Levitan’s pre conference airway workshop and a
number of airway talks:
Airway workshop
• Hot cases with panel discussion (ICU, Anaesthetists, ED, ENT)
• Videolaryngoscopy station
• Fibreoptic nasal ‘intubation’ session
• Practical vortex tips
• Weingart’s “scalpel-finger-bougie” with tips
Airway hot cases:
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Man in 40s BIBA post crush injury upper torso, deteriorated prior arrival ED
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Tx with intubation by direct laryngoscopy (face/larynx – no visible injury), bilateral
chest tubes. Sudden decreased O2 saturation. Trauma surgeon performed open
thoracostomy – nil obvious. Unable to be resuscitated. Autopsy found upper trachea
“squashed” again side of vertebrae. Discussion regarding proceeding straight to
surgical airway with facial and laryngeal trauma. Weingart suggested using Ketamine
10mg IV increments to facilitate ‘awake’ surgical airway with local anaesthetic. All
agreed tricky to secure trachea esp with risk transection in crushing trauma
Airway Hot Cases (cont.d)
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Man in 60s admitted to ICU for asthma who deteriorated overnight. Reg performed
RSI, laryngoscopy revealed laryngeal tumour obscuring vocal cords and obstructing
AW. Anaesthetist rapidly attended and intubated with bougie and small ETT. Panel
discussion recommended surgical airway and NOT attempt to intubate through
tumour (bleeding risk, pushing tumour down airway/bronchial tree)
Videolaryngoscopy – practical tips with toys
• Use like standard laryngoscope then look at ‘video’
• Recommend use of bougie for all
• For big chests, insert blade at 90degrees (i.e. handle and blade to patient’s right,
then rotate to front
• McGrath – small handle avoiding pitfall of patient with big chest and issue with
insertion of blade. Con – battery finite and not rechargeable
• King Vision – similar to McGrath with longer blade
• Mac 3 – base battery/power unit with interchangeable blades (e.g. mackintosh,
Millers)
• New Mac D extra curved for trauma and ‘anterior’ larynx
• Now comes in disposable
Fibreoptic nasopharyngoscopy
• Storz
• Cophenylcaine spray
• Tristal wipes for cleaning
• Consider purchase of second-hand
• Practical applications in ED – FB (esp pesky fishbones), airway burns
Cut to air, Scalpel – finger – bougie
• Weingartism
• Airway anatomy and technique - midline is a safe place to go
• Protected by posterior cricoid cartilage posteriorly and articular joints laterally
• http://emcrit.org/smacc/airway-workshop-surgical-airway/
• Steady hands on patient’s sternum
• If cannot locate anatomical landmarks, start at sternal notch and retract adipose
tissue as cut with scalpel until cricothyroid membrane palpable
• Palpate posteriorly cricoid cartilage, then feed bougie against fingertip till reach
carina
• Rotating size 6-6.5 ETT will enable easier passage
• Blood loss minimal and easily controlled with direct pressure including accidentally
cut vessels – video illustrating this
The Vortex
Vortex tips
• Bag valve mask tips – enable better seal of mask to face with thumb and thenar
eminence on mask and index to little fingers along jaw
• Laryngeal mask – various types
• NG tube opening – use bougie to stiffen laryngeal mask to prevent mask
tongue kinking during insertion
• Bougie
• Pre-primed bougie with ETT
• Once inserted bougie, let go and rotate ETT only clockwise to ease passage past
overhanging epiglottis
Airway tips from expert presentations:
• Weingart
• Palpate anatomy and mark ‘X’ on cricothyroid membrane on all patients prior
intubation
Levitan
• Obese patient – sit patient upright, mandible forward, nasal high flow O2
• Apnoeic oxygenation with high flow nasal prongs at 15L O2
• Use pre RSI and during intubation until ETT secured
• Reservoir of O2 posterior nasopharynx
Greenland – 2 curve airway concept for predetermining airway difficulty
• Anterior column – face shape, buck teeth/receding chin aka anterior larynx, Ludwig’s
angina
• Posterior column – neck movement
• The actual airway - airway obstruction, FB
• Obese/pregnant patient – CPAP to reduce atelectasis
• Combination of BVM with PEEP valve and nasal cannulae most effective
• Consider as standard for all intubations
Aortic crisis – Rob Rogers
• 50% miss rate no matter what we do!
• Suprasternal notch US to view dissection flap at ascending and arch aorta
• 5 tips to help not to miss
• 70% have symptoms above and below diaphragm
(e.g. 50yr old with severe neck pain and transient leg weakness)
• Chest pain and another symptom
(e.g. chest pain and severe leg pain)
• Severe chest pain or back pain with intractable vomiting
• Young patient with abdominal pain and hypertension
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(most commonly Marfans or drug use)
• Patient just looks bad!
Status epilepticus – Oliver Flower - Intensivist
• Change in definition
• Currently seizure greater than 5 minutes, or 2 seizures back to back with
minimal recovery time
• Prior definitions of 30 minutes based on primate experiments whereby
microscopic brain injury would be seen at half hour of seizure activity
• Treatment
• 1st line – Phenytoin – need to given enough and wait for enough time to allow
effectiveness
• 2nd line – GA with infusions of Midazolam/Propofol/Thiopentone
• 3rd line – Kepra loading 2-3g with infusions
• New – Lacosamide
• Use of synergistic verapamil to increase CNS levels of antiepileptic
• No evidence for efficacy of ketamine as yet
Anaphylaxis
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?Change in clinical definition as often no skin alterations although listed with skin
manifestations and either one of GIT/Resp or CVS
May not be IgE mediated
Pholcodeine – some structural similiarities with neuromuscular blockers – issue with
anaphylaxis with 1st anaesthetics
Chlorhexidine in urethral gels and other premade formulations
IV Paracetamol – mannitol component in IV preparation is sensitising allergen
No real true increase in anaphylaxis between:
• shellfish and iodine
• Egg and propofol (egg white allergy, and propofol made from yolk
component)
True increased risk correlation of red meat allergy with ticks and use of gelofusine
To investigate do mast cell tryptase at 1/24, 4/24 and 24/24
Management algorithms – ANZAAG
State of the art Cardiac arrest - Scott Weingart
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Practise intubating during CPR in simulation
More effective ventilation if attach to ventilator and set peak pressure limits to
100cm
Minimise interruptions to chest compressions by:
New See through analysis ECG monitors
External CPR machines
‘Hands – on” defibrillation
PCA trial (Resuscitation) – Adrenaline effective for ROSC
Vasopressin not completely buried yet – JAMA 2013 – Vasopression and steroid
some effectiveness for cerebral perfusion
Adrenaline infusion dosing by diastolic BP approximately 40mmHg and arterial line
RUSH – Rapid US for shock haemodynamics
E-CPR – ECMO CPR (www.edecmo.org)
Peter Papadopoulos:
Trauma
Karim Brohi @karimbrohi
Professor/Trauma Director Royal London Hospital
Trauma.org
Ain’t got time to bleed
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Cannot just break a femur in a motorbike accident.
Beware of broken foot and LOC !
Boot off on the race track = catastrophic event: ankle needs to rotate to lose your
bootfemoral and pelvic #s !!
Avoid :
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INR > 1.2  mortality doubles  INR > 1.5 doubles again !!
Acidosis , pH < 7.1
Hypothermia, T < 32
Haemostatic resuscitation involves:
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Early haemorrhage control
Permissive hypotension
Limited fluid infusions
Target coagulapathy
Acute Traumatic Coagulopathy (some pathophysiology)
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Clot strength rather than prolonged APTT is the problem :
o Clotting factors are not low.
o Diminished fibrinogen: often come in at ½ Normal decreases substancially
 Mx : cryoprecipitate can help maintain levels.
o In addition increased fibrinolysis
Body’s response to trauma:
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Haemorrhage
Catastrophic organ dysfunction
Sepsis
Persistent inflammatory catabolism syndrome (PICS)
Magnitude and duration of insult determines final outcome.
Blood substitutes
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Chemicals : perfluorocarbons
Carriers: substitute Hb, earthworm Hb, polyHb-Fg (fibrinogen attached)
Components: platelet microparticles.
Nothing ready for prime-time
ATLS
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ADR
VSE = vasopressin, steroid, BRAIN
Aim for diastolic BP ≥ 40 use artline in resus ADR used to maintain diastolic BPs.
RUSH protocol vs TOE
ECMO CPR www.edecmo.org
Peter Jordan:
Paediatric Resuscitation
Francis Lockie Paediatric Intensivist -PETS/ NETS Retrieval Director South Australia
“Paeds resus should be like a big Mac…” i.e. consistent..
Preparation is key:
Checklist pre RSI useful – done in rapid fire fashion takes little time
Brief team pre RSI
I'm going to do...
Plan B is...
Plan C is..
PEEP critical if using BVM
(Should ban standard BVM)
Decompressing the stomach pre RSI very helpful – may even preclude the need for RSI!
Pain related to IO insertion in children well studied. Not v painful..pain scores 2.3/10
(less than standard IV) but..more painful once infusing fluids/ drugs.
Do a VBG early in sick kids.
Quality/ Adverse events/ Error
Prof Stuart Lane – Intensivist – RNSH Sydney
If you want to be an awesome doctor you have to be an awesome communicator..
Avoid euphemistic language.
The hallmark of professionalism is integrity
Critical reflection critical to professional development.
Communication
Professor Imogen Mitchell.. The Canberra Hospital - Director ICU
Patient Centred Care improves outcomes:
Patients like:
Uniforms
Patient advisors.
Introductions
Smiles
Know your patients
Find out what matters to them.
Listen
ECGs
Dr Steven Smith Associate Professor EM Minneapolis USA
@smithecgblog
Dr Smith’s ECG Blog
Hqmeded-ecg-blogspot
NSTEMI - 30% have occluded coronary arteries @ PCA.
ECG is extremely accurate
Subtle changes commonly underappreciated - Many have subtle changes particulary ST
segments.
Most non ischaemic ECGs have subtle ST elevation at V2 & V3 at baseline.. If ST depression
this is often abnormal and suggests acute ischaemia.
ST depression in V2 and V3 is a STEMI equivalent.
New validated formula to determine if ST elevation significant.
Calculator on blog (see above) . R wave amplitude/ Voltages critical
Smaller R = smaller ST changes
Wellens means artery has been closed and is now open
ST segment monitoring important
If considering pericarditis ..should not see ST depression
ECGs Stephen Smith (cont.d)
Always look carefully at aVL – if ST depression - beware
Don't let age dissuade. Even without Risk factors
Posterior leads...often small voltages therefore smaller ST elevations..Not as sensitive as
anterior leads but because ST elevation seen rather than depression Cardiology doctors
more likely to recognise significance and take for PCA.
De Winter Ts = ST depression followed by peaked Ts another STEMI equivalent
Risk Factors for Acute Coronary Syndrome
Simon Carley Professor Emergency Medicine Manchester Royal Infirmary
@EMManchester
Stemlynsblog.org
Presented Case studies and Evidence that showed extremely poor correlation between
traditional Risk Factors for Coronary Heart Disease and STEMI/ Major Adverse Cardiac
Events/ Death.
Similar findings in other conditions.. History of presenting symptoms much more significant.
Take Home Message – Don’t discount the possibility of Cardiac Cause of Chest Pain (and
other significant pathology) based on absence of traditional risk factors.
Chest Pain Evaluation
Louise Cullen EM Professor Brisbane
@louiseacullen
Discussion of Diagnostic Strategies for Chest Pain. (see other communication and Blog entry)
Troponins are Excellent Biomarkers but strategies need to put in place to ensure lack of
specificity does not lead to overdiagnosis.
- Need more than a single troponin to add MI
- Good history and ECG interpretation remains critical
Antibiotic Use
Jeffrey Lippmann Professor/ Intensivist Royal Brisbane
Antibiotic resistance can begin <24/24 and can occur after 1 dose..
There are no current biomarkers proven helpful for initiating Antibioticsr rapid confirmation
of bacteraemia.. 2-3 yrs from availability.
Do not delay Antibiotics in severe sepsis But...think before using.
Good clinical acumen key.
Sepsis
Scott Weingart Intensivist/ Emergency Physician Mt Sinai New York
@EmCrit
EMCrit.com
Discussed experience form large ongoing multicentre study of Sepsis Protocol in NY
hospitals.
Process improvements can achieve <20% mortality for septic shock
95% gains are from simple process changes and education
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602
ARISE (Australasian) and PROMISE (UK) studies are nearing completion and will shed further
light on this area.
Some of the reported improvement in sepsis outcomes are due to Denominator shift i.e.
Many more patients are being classified as having severe sepsis or septic shock due to
increasing use of Lactate and use of elevated Lactate >4 to differentiate/ code these
patients. i.e. Patients previously coded as pneumonia have become sepsis.
Having a Code Sepsis is helpful
Initial lactate measurement (VBG) is helpful for identification/ risk stratification but repeat
lactates are not that helpful.
Lactate clearance does not = survival
Rebounders (Lactate) do badly.
Antibiotics need to be immediately available. Most can be simultaneously infused.
Most patients require 2 or 3 L balanced crystalloid fluid (if IVC collapsed) quickly then stop
or slow down. If still shocked after 20-30ml/kg start vasopressors. (peripherally or centrally)
Ricard et al..Criticalcaremedicine 2013 41(9):2108-15
Source control is critical when relevant- don’t delay theatre for further resuscitation.
Invasive lines/ monitoring only needed if using vasoactive drugs.
No-one knows the optimal target for MAP – Recent study comparing different goals showed
no difference when a Target MAP of 65 was compared with MAP 85.
No evidence for targeting MAP>65
"High versus Low Blood-Pressure Target in Patients with Septic Shock"
http://www.nejm.org/doi/full/10.1056/NEJMoa1312173
Shock – Are BBlockers Useful?
John Myburgh - Professor/ Intensivist RNSH Sydney
Survival largely due to venous constriction
Fluid of choice in septic shock is NorAdrenaline (semi-seriously)
Different strategies required for compensated v decompensated shock.
B blockers do not protect the heart from increased metabolic demand
1 x inadequately powered trial shows strong mortality benefit with esmolol.
but….Don't believe in magic bullets..
BBlockers may have some beneficial immune-modulating action but we don’t know what
that is and they cannot be recommended at present.
Education
Victoria Brazil Educator/ Researcher/ Emergency Physician Brisbane
@SocraticEM
Useful site with resources/ evidence in Medical education:
www.bemecollaboration.com
Education and behaviour change are closely aligned
What works:
Structured interventions
Reminders,incentives, checklists
Simulation
Short, Low Volume, High frequency
Involvement in care/ Integration
Repeated interventions required
Use of internal teams
Audit and Timely feedback od progress
Dogmalysis
Dr Cliff Reid Director Sydney HEMS
@cliffreid
Resus.me.com
Listed a number of resuscitation and airway assertions which have no evidence base or
evidence contradicting their benefit:
No useful association between gag reflex and aspiration risk
Failure of needle cricothyroidotomy common (NAP4= 40%)
Open cricothyroidotomy is now recommended.
In kids... Can do tracheostomy or Cricothyroidotomy
Sutures are helpful to elevate trachea.
Biggest problem is delay or failure to act.
Maternal arrest...just do LUSCS
Good outcomes despite delays.
It may not be too late.
Acidosis does not cause low Cardiac Output
Noradrenaline – can start peripherally if good large bore peripheral cannula in-situ:
Requires close observation.
Ricard – Critical Care Medicine. 2013 41(9):2108-15)
Decreased LOC is not a Contraindication for NIV (with careful trial)
Pulses are useless for BP estimation
Evidence for Cervical Collars very weak- Collared patients are better off with 2-4cm head
support.Whatever leaves face horizontal (if supine) or neck in neutral position. Can sit up w
collar on if thoracic/ Lumbar spine not injured.
Log rolling can be dangerous
Do not routinely do a PR on awake trauma patients
Permissive hypotension...no good outcome evidence. Optimise perfusion and tailor to
individual case
Ketamine at sedative doses more likely to cause euphoria than dysphoria.
Morgs Carlyon:
- introducing self, sitting down and listening to what pts have to say for a minute without
interrupting #hellomynameis
- ALL ivabs can be given at same time
- FACEMS thrash a mean air guitar
- john farnham gets drunk medicos rocking
- ask patients what they expect (ie comfort vs cure)
- no matter how hard you try, simwars will always fuck you up
Having two team leaders to run a resus is an option to consider - the nurses can run the
ACLS side of things (after all, its just following a flow chart, and the dopey nurses can surely
do this) whilst the medical team leader works on reversible causes/advanced therapies.