In anaesthetics we are trained to pre-oxygenate and intubate our theatre patients in a flat supine position. Then, when we graduate to intubating the really gnarly ICU/ED patients in severe heart or respiratory failure, we wise up. A paper in Anaesthesia & Analgesia demonstrates how patients who are intubated in a semi-sitting position are less likely to suffer complications when intubated. More>>
Interesting paper in AJEM. Hypoxic hepatitis (HH), ‘shock liver’, is defined as an increase in serum aminotransferase levels (20 times the upper normal level) after respiratory or circulatory failure. It is commonly seen in critical illness and after cardiac arrest. In ICU patients HH has been associated with poor outcomes but little is known about what it means in ROSC patients. More>>
We’ve often critisised ATLS. Part of it because many healthcare workers take the ATLS manual as divine law. And many of them don’t keep up with the changes in the new ATLS editions – so they cling to even older dogma. Pretty much everybody has stopped giving 2 L of saline, but many will still say things like the digital rectal exam (DRE) is manadatory in ATLS. It isn’t. Or a hard cervical collar is mandatory. It isn’t.
ATLS is now at the 9th edition, and the 10th edition is around the corner. What other dogma will they get rid of, and what will they add, and get more in line with current trauma thinking? Well, here’s a teaser:
They have moved the temporary measure of needle decompression from the thick pectoral muscles, and out on the side of the chest – although a finger thoracostomy would be more decisive and definitive.
They’ve even gotten rid of the high riding prostate sign, although they should have gotten rid of, or at least toned down the whole DRE – and log roll for that matter.
Now, ATLS is a big organisation and not as fast moving and flexible as we would want to, but they are moving forward. For their 10th edition, it seems they will be catching up on many important areas.
Besides being one of the better study names around, this Norwegian RCT in the Lancet also shifted my prejudice. I was really thinking invasive vs conservative treatment for those over 80 with NSTEMI/UAP would show little difference. Maybe even a win for conservative treatment. But the scales tipped quite heavily in favour of invasive treatment. More>>
Videolarygoscopy (VL). Brave new world. VL makes any intubation easy, and solves airway managment problems. Well, it can be a life-saver, but it also brings its own set of problems. Two new RCTs comparing VL and DL are just out. One study looks at using VL as the primary intubation tool in the pre-hospital setting, and next to the old laryngoscope it pales in comparison. Bit there might be more to the story. Let’s have a look.
We’ve held on to our strict fasting regimes for decades. Gastric ultrasound is here to help us individualise our fasting rules a bit more. Gastric ultrasound has lots of uses, and lately it’s become fashionable to use it for evaluating surgical patients immediately pre-op to see if they’re fasted.
There´s a nice Best BET mini review in EMJ April 2016. The authors ask if it is safe and beneficial to control hypertension in the acute/hyperacute phase (~<6h from presentation) in patients with acute intracerebral haemorrhage. More>>
This was one of my favourite SMACC CHICAGO debates: “Predicting Fluid Responsiveness is a Waste of Time” on fluid management, Rob MacSweeney pokes at the fluid response hero/enfant terrible Paul Marik. Great points by both, and Rob’s cartoon is epic! Watch, learn and enjoy!
Thanks to Scott Weingart for editing this video – and letting us share it! See his post at EMCRIT, and the full post on this debate at Intensive Care Network for the original audio and Marik’s slides. Can’t wait for SMACC DUB!
Propofol is a great anaesthetic – but it can cause pain on injection. This is one of the tricks of the trade: mix in some lidocaine in your propofol syringe, and the patient is pain free. Sounds like magic. Especially as there’s no way lidocaine can work its usual local anaesthetic effect that quickly. But it works. There’s been a lot of studies on the subject, and now there’s a Cochrane review too. More>>
There’s a new RCT out in NEJM on amiodarone and lidocaine in cardiac arrest. It’s an interesting study we wrote on, but needed a less categorical take. In the unselected study population, amiodarone and lidocaine did little for the patients. In selected patients, it might help a little more. We’ll look at it in more detail. More>>