17 y/o male presents in severe respiratory distress secondary to asthma exacerbation. Patient is intubated using combination of etomidate and succinycholine. 10 minutes later he begins to take a turn for the worse becoming rigid, febrile (108 F), tachycardic and acidodic (both metabolic and respiratory). What is the diagnosis? Treatment?

Malignant hyperthermia, is an entity often written about (as in this vignette) but rarely - if ever - seen in the emergency medicine community.  In a brief review of the literature, I found no case reports of malignant hyperthermia presenting in the ED.  While malignant hyperthermia can occur after administration of succinycholine alone, it is a more common complication in the OR where succinycholine is combined with inhaled anesthetic gases .  Treatment is dantrolene, a drug with minimal side effects, which will decrease mortality from as high as 70 percent to between 1 and 17 percent. 


Source

Litman, R.  "Malignant hyperthermia: Clinical diagnosis and management of acute crisis"  Up to Date.  May 2011.

Rosero, E.  et al.  "Trends and Outcomes of Malignant Hyperthermia in the United States, 2000 to 2005.  Anesthesiology.  2009.

How do you perform a cricothyrotomy? Here are videos of my favored techniques.

There are a bunch of devices and associated techniques to perform a cric.  Below I have posted videos of my favorite technique to perform a standard cric and needle cric.  These are my preferred methods because they can be performed with items lying around any standard ED and don't rely on having any special equipment (ie jet ventilator, etc ...) - which often seems to go missing when needed most.

Bougie-Aided Standard Cric (hat tip to EMCrit)




Needle Cricothyrotomy




Source

Video, Bougie Aided Standard Cricothyrotomy: http://www.youtube.com/watch?v=wVQFJR7qmrQ&feature=player_embedded

Video, Needle Cricothyrotomy: http://www.youtube.com/watch?v=Fq5YCpYTYUY

At what age does the surgical airway technique of choice transition from needle cricothyrotomy to standard (percutaneous or open) cricothyrotomy?

10 years old.   Standard cric should be avoided in children less than 10 years old.


Source

Marx: Rosen's Emergency Medicine, 7th ed.

Given that 50 to 70 percent of cases of sudden cardiac arrest are secondary to myocardial infarction or pulmonary embolism should empiric thrombolysis be considered?

Yes it should be considered as there are isolated case reports of dramatic success however, the majority of data does not demonstrate a systematic benefit.


Source

Pozner, C. "Therapies of uncertain benefit in basic and advanced cardiac life support" Up to Date. 2011 Jan.

Rosiere, L. et al. "Fibrinolysis and Thrombectomy for Massive Pulmonary Embolus" American Journal of Therapeutics. 2011.

Does intubation with succinylcholine or rocuronium affect pupillary response?

No.  If there is a change in pupillary response after intubation with succinylcholine or rocuronium and there are no mitigating factors (ie opioid administration, etc) then a neurologic injury should be suspected.


Source

Caro, D. et al.  "Pupillary Response to Light Is Preserved in the Majority of Patients Undergoing Rapid Sequence Intubation"  Annals of Emergency Medicine.  March 2011.

Case report: 81 y/o female survives, neurologically intact, after prolonged resuscitation

81 y/o female with no significant past medical history presents to Dr. Bearemy's ED with chest pain.  En route to the hospital by EMS, patient was noted to have two runs of VT which responded to cardioversion.  Upon initial ED evaluation patient's vitals were stable and an EKG noted ST elevations in the inferior leads.  Cath lab was immediately notified and the usual pre-cath cardioprotective drugs were administered.  Minutes later, the patient began to have recurrent runs of V fib with loss of pulse.  ACLS measures were initiated.  After 30 minutes, intubation, 30 shocks, 10 mg of epi, 3 mg of  atropine, magnesium, amio bolus and drip, bicarb and a wide open dopamine drip, the patient regained a sinus rhythm with thready pulse and was taken to the cath lab where despite continued hemodynamic instability an occluded RCA was stented.  Patient remained in the CVU for several days where balloon pump, vasopressor and ventilatory support were gradually weened.  5 days post stent, the patient is neurologically intact with little evidence of hypoxic ischemic brain injury and retains a good cardiac ejection fraction despite some inferior wall akinesis.

After the initial resuscitation, I had prepared the patient's family for the worse but am glad to see that the patient made a fool of me.  It's cases like this that make the tough days palatable.

While I am quite impressed with the outcome of this case, there's a real case report in the American Journal of Emergency Medicine of a good neurologic outcome after 60 minutes of CPR. 

This is the BEST vent lecture that I've ever heard

"How to Dominate the Ventilator" by Scott Weingart

Succinct
Insightful
Practical

My management strategy has just evolved dramatically. Thanks Scott.


Source

http://learn.emcrit.org/uncurated-videos/

For how many minutes, according to the AHA, should the resuscitation of a newly born baby be conducted if born pulseless and remains so despite resuscitative efforts?

10 minutes.


Source

"Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care."  Circulation 2010.

What is the ideal route for epinephrine administration for the initial treatment of anaphylaxis?

IM in anterolateral thigh q 5 - 15 minutes x 3.

Absorption is more rapid and complete in this location relative to SC; IM in deltoid.

Because of the risk for potentially lethal arrhythmias, epinephrine IV should be avoided unless the patient is in cardiac arrest or profoundly hypotensive despite multiple epinephrine IM injections and IV fluids.


Source

Oswalt, M. and Kemp, S.  "Anaphylaxis: Office Managment and Prevention"  Immunology and Allergy Clinics of North America.  May 2007.

Push here to save the day: Laryngospasm Notch

Laryngospasm is a rare but well know complication of using ketamine for conscious sedation, particularly in young kids. Treatment for this involves the usual maneuvers:

• Chin lift 
• Jaw thrust 
• Suction
• Positive pressure ventilation via bag-mask, occluding pop-off valve if necessary to generate high enough pressures to open the vocal cords 
• Neuromuscular blockade 

Another helpful albeit less well known technique that can be tried is application of pressure to the laryngospasm notch.

The mechanism by which this technique works is uncertain but it is endorsed in the anesthesia literature.  Click here to read a good review of this technique by Dr. Philip Larson, a Professor Emeritus of Anesthesia and Neurosurgery at Stanford.


Source

Gorelick, M et al.  "Pediatric Sedation Pearls"  Clin Ped Emerg Med. Dec 2007.

Larson, P. "Laryngospasm - The Best Treatment"  Anesthesiology.  Nov 1998.

Revised Powerpoint Slides on Ethics of Resuscitation 2010

I have just uploaded my revised version of Ethics of Resuscitation slides. The lecture was given during the Master of Medicine Intensive Course on Bioethics & Communication 2010.Go the the original source where this file is hosted and click on the download link for FREE download. I allow for FREE download for non-commercial use ONLY as long as I am acknowledged as the author of this work, and

Name five circumstances in which amiodarone should be avoided with wide complex tachycardia. Here's a freebie: patient is unstable.

An Oldie but Goodie ...

1. Patient is unstable. Shock instead.
   
2. Patient is pregnant. Amiodarone is class D. Consider lidocaine (class B - no evidence of risk to humans) or procainamide (class C - risk can't be ruled out) instead.
3. Patient is in atrial fibrillation with WPW. Amiodarone has AV nodal blocking properties which encourages conduction down the accessory pathway and may induce ventricular tachycardia/fibrillation. Consider procainamide or shock instead.
   
4. Torsades. Amiodarone will prolong the QT interval making things worse. Consider magnesium instead.
   
5. Accelerated idioventricular rhythm. AKA "slow VT." This rhythm arises below the AV node and has a rate between 50 - 120 beats/min. It can be an escape rhythm or represent an abnormal ectopic focus in the ventricle that competes with the sinus node. Pharmacologic treatment is CONTRAINDICATED if AIVR is an escape rhythm (as it often is in setting of myocardial infarction), since supression of the pacemaker focus can result in asystole. There is no convincing data linking AIVR to sustained VT or VF.

Source

Mattu, A. MD. EM Cast: Amiodarone Imperfections. Dec 2008. http://www.emedhome.com

Podrid, P. MD. "Ventricular arrhythmias in heart failure and cardiomyopathy" Up to Date. Oct 2008.

What is abdominal compartment syndrome (ACS)?

Organ failure caused by excessive intra-abdominal pressure (> 12 mm Hg) which decreases preload and increases afterload, leading to decreased end-organ oxygen perfusion.

Three forms of ACS:

1. Primary: stems from hemorrhage
   
2. Secondary: associated with vigorous volume resuscitation with the acute formation of ascites as well as visceral edema. Increasingly common after initiation of early goal directed therapy for sepsis.
   
3. Recurrent: an ACS that recurs secondary to extravasation of fluid via loss of capillary integrity caused by end organ ischemia

Treatment:

1. Treat underlying cause
   
2. Decompressive laparatomy with temporary abdominal wall closure if option 1 not enough

Source

Maerz, L et al. "Abdominal compartment syndrome" Crit Care Med 2008.

Ethics in Resuscitation

Ethics in ResuscitationView more presentations from cksheng74.Other Important Points Not Covered in the Lecture:The Concept of Patient Autonomy“Every human being of adult years and sound mind has the right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable”- Justice Cardozo in

Does your standard rapid seuence intubation (RSI) technique need to be modified when intubating patients with myasthenia gravis (MG)?

Maybe. Depends on your technique.

• MG patients are supersensitive to nondepolarizing muscle relaxants. Avoid if possible otherwise use smaller amounts, 0.1 - 0.05 of the normal dose, as this will be enough to block the fewer number of acetylcholine receptors. If used in usual doses, prolonged weakness may ensue.
  
• MG patients have a resistance to succinylcholine. A higher dose in the range of 1.5 - 2 mg/kg should be used. Preoperative administration of pyridostigmine or other anticholinesterase inhibitors used to treat MG, however, may prolong the action of succinylcholine.

Source

Barash, P. MD. , Clinical Anesthesia. Lippincott Williams and Wilkins. 2001.

Dunn, P. MD., Clinical Anesthesia Procedures of the Massachusetts General Hospital. 7th ed.

Bowman-Howard, M. MD. Anesthesia Review. Lippincott Williams and Wilkins. 2007.