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Up and Coming in the EM World
- 1. UP AND COMING IN THE EM WORLD Jonathan Schonert, MD WVU Emergency Medicine
- 2. TOPICS • Capnography (specifically in cardiac arrest) • Apneic oxygenation • Tranexamic acid in trauma • Coronary CT angiography • Needle decompression for tension pneumothorax • Ultrasound guided subclavian central access
- 3. TOPICS • What is it? • Why do I care? • How do you use it? • Limitations
- 4. DISCLAIMER
- 5. CAPNOGRAPHY
- 6. CAPNOGRAPHY • Capnography = monitor for ventilation • In cardiac arrest, capnography = cardiac output
- 7. CAPNOGRAPHY • Monitor that measures quantity of CO2 in the air • Capnography - measurement of CO2 over time
- 10. CAPNOGRAPHY • Infrared beam shot at the air. IR ray can be absorbed by different polyatomic gases. Carbon dioxide absorbs specific wavelength. • Amount of light absorb is proportional to concentration of gas.
- 11. TWO TYPES OF DEVICES Mainstream Sidestream
- 12. TWO TYPES OF DEVICES Mainstream Sidestream • Advantages: Can be used • Advantages: sensoryat for non-intubated endotracheal tube. No patients, great for chance of obstruction/kink. conscious sedation. • Disadvantages: unable to • Disadvantages: Delay in do non-intubated patients recording due to unless using NIV mask. movement of gas from tube to sensor. Possible obstruction potential.
- 14. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 15. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 16. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 17. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 18. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 19. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 20. CAPNOGRAPHY IN CARDIAC ARREST etCO2 = pulmonary perfusion = cardiac output
- 21. CAPNOGRAPHY IN CARDIAC ARREST After 20 minutes, no chance of survival if etCO2 below 10mmHg in cardiac arrest without pulse and electrical activity on monitor.
- 22. CAPNOGRAPHY IN CARDIAC ARREST After 20 minutes, if etCO2 above 14.3mmHg, predicted better chance of ROSC. If under this, 100% sensitive for no ROSC.
- 23. CAPNOGRAPHY IN CARDIAC ARREST Not perfect. Various factors still come into play. The rhythm and cause (particularly PE) can cause differences in CO2 levels.
- 24. WHY SHOULD I CARE? • AHA in the 2010 guidelines now recommends capnography not only for augmenting endotracheal tube confirmation, but for monitoring effectiveness of chest compressions. • Another feather in your cap for the wonderful cardiac arrest. • Paramedics/flight teams are using it and YOU should know more than them.
- 25. 96 MINUTES OF CPR
- 28. PREOXYGENATION • Concise10 page paper on everything you need to know to understand the what and why behind preoxygenation. • 10 questions asked with evidence based summary answer. • Includes patient positioning, best paralytic, usual time lengths for preoxygenation to be adequate, etc..
- 29. WHICH PROVIDES BETTER PERCENTAGE FI02? or
- 31. APNEIC OXYGENATION • Alveoli will continue to take up oxygen even without ventilation or the diaphragm moving. • Due to continued consumption, gradient from airway to alveoli leans toward gas moving toward alveoli. • PaO2 can be maintained at 100mmHg for up to 100 minutes without ventilation in optimal conditions.
- 32. APNEIC OXYGENATION • Continued oxygenation, but still can’t ventilate so CO2 continues to rise and potential for worsening acidosis. • Nasal cannula is the device of choice. • 15L/min provides 100% FiO2, though patient has got to be out of it (RSI). • Perfectfor maintaining oxygen saturation during difficult intubation. • No downsides to doing it.
- 34. TRANEXAMIC ACID
- 36. TRANEXAMIC ACID • Antifibrinolytic agent. Stops clot breakdown. • “Notvery powerful. Only slightly changes balance in coagulation process.” • FDAapproved for hemophiliacs undergoing dental surgery or menorrhagia. •~ $100-200 a dose.
- 37. • 20,000 patients, 270 hospitals, 40 countries. • Givenif physician felt trauma patient was at risk of needing blood transfusion. Must have been within 8 hours of incident. • Given1G tranexamic acid over 10 minutes, then another 1g over the following 8 hours. • Observed mortality/morbidity of patients for 4 weeks after injury.
- 38. 20,211&randomised& 10,096&allocated&TXA& 10,115&allocated&placebo& 3&consent& 1&consent& withdrawn& withdrawn& 10,093&baseline&data& 10,114&baseline&data& 33&lost&& 47&lost&& to&followGup& to&followGup& Followed&up&=&10,060& Followed&up&=&10,067& (99.7%)& (99.5%)&
- 41. • Found relative risk of death reduction of 9% and specifically from bleeding by 15%. • The more sick you are, the more benefit you would likely receive. • The faster you give it, the better outcome you would get. • Ifyou’re giving your first PRBCs, you should be giving tranexamic acid along with it.
- 42. PROBLEMS • Verylarge variety of trauma centers (though all centers had decrease in mortality). • Did not look at assays, only mortality/morbidity. • No change in amount of blood transfusions given in TXA vs placebo patients (survival bias). • Not FDA approved.
- 45. NNT
- 46. NNT • Tranexamic acid: 1 in 67
- 47. NNT • Tranexamic acid: 1 in 67 • Aspirin: 1 in 42
- 48. NNT • Tranexamic acid: 1 in 67 • Aspirin: 1 in 42 • Magnesium for pre-eclampsia: 1 in 90
- 49. NNT • Tranexamic acid: 1 in 67 • Aspirin: 1 in 42 • Magnesium for pre-eclampsia: 1 in 90 • Heparin for ACS: 0
- 50. MATTERS TRIAL
- 51. WHY SHOULD I CARE? • Its CHEAP ($100-200). • Itsbeing used in trauma centers worldwide, including some in the USA. • No side effects seen in trials. Only benefit. • Only drug to show all-cause mortality reduction from bleeding in trauma in a large quality study.
- 53. CCTA
- 54. CCTA • Basically supa detailed CTA of the heart. • 16cm block of heart can be scanned in one heart beat. • Less radiation exposure than MPS, most other CT scans. • Some protocols use beta-blockers, etc. • At least 64 slice scanner needed.
- 56. •5 centers, various protocols to make external validation more likely. • >30yo, concern for ACS, TIMI score 0-2. Considered low risk. Normal EKG, negative trop. No other alternative diagnosis. • Compared traditional workup vs CCTA for low risk chest pain. • For every 1 in the traditional group, 2 were placed in CCTA.
- 57. • 9% diagnosed with CAD with CCTA group vs 4% in traditional group. • 50% discharge with CCTA vs 23% discharged traditional. • 1% MI at 30 days for both groups. • Length of stay less than 8 hours.
- 59. CCTA
- 64. NEEDLE DECOMPRESSION • Can go 2nd ICS, midclavicular, but GO BIG or GO HOME. • 5thmid anterior axillary line (basically chest tube) has better success rate.
- 65. UTLRASOUND GUIDED SUBCLAVIAN ACCESS
- 66. SUBCLAVIAN ACCESS • Recommended by the CDC for least risk of catheter induced infection and DVT. • Can place for CVP or ScVO2 with cervical collar on. • Most comfortable line for a patient (once its in)
- 71. ULTRASOUND GUIDED SUBCLAVIAN ACCESS
- 72. ULTRASOUND GUIDED SUBCLAVIAN ACCESS
- 73. ULTRASOUND GUIDED SUBCLAVIAN ACCESS
- 74. ULTRASOUND GUIDED SUBCLAVIAN ACCESS
- 75. ULTRASOUND GUIDED SUBCLAVIAN ACCESS
- 76. • etCO2 = pulmonary perfusion = cardiac output • apneic O2 = more time for intubation • Tranexamic acid = better evidence than tPa • Tension pneumo = think 5th ICS at chest tube site • Doingsubclavian line = consider throwing on the US probe while doing it. • CCTA = likely future, though same problem as always with low risk chest pain.
- 78. REFERENCES • capnography.com • academiclifeinem.blogspot.c om • emcrit.org • crash2.lshtm.ac.uk • ercast.org • smartem.org • thelancet.org • ultrarounds.com • regiontraumapro.com • thennt.com
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- Howard Snitzer, a 54-year-old chef from Goodhue, Minn\n\nThe technology records CO2 pressure in milligrams of mercury. Research by White and others shows that if the maximum CO2 pressure achieved during 20 minutes of CPR is 14 or less, resuscitation is almost certainly futile. If the level is above about 25, "you need to keep working at it until you've exhausted all of your tricks," White said.\nWhen Goodman and his co-workers hooked Snitzer up to the capnograph upon their arrival, they were impressed with his CO2: It was in the low 30s. A normal level in healthy adults is between 35 and 45. But after the effort went on for 45 minutes, Goodman became concerned. In his 15-year career as a paramedic, the longest successful CPR case he'd been on was about 45 minutes.\n\n\nRead more: http://www.foxnews.com/health/2011/05/17/6-minutes-heartbeat/#ixzz2BSwhY23I\n
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- Three minutes’ worth of tidal-volume breathing (the patient’s normal respiratory pattern) with a high FiO2 source is an acceptable duration of preoxygenation for most patients.15,1\nPatients should receive preoxygenation in a head-elevated position whenever possible.\n\n
- True nonrebreather masks set at 15 L/minute for patients with normal ventilatory patterns are capable of delivering near 90% FiO2,9 but these devices are rarely available in EDs. Standardly available nonrebreather masks at flow rates of 15 L/minute deliver only 60% to 70% FiO2.\nStandardly available nonrebreather masks can deliver FiO2 greater than or equal to 90% by increasing the flow rate to 30 to 60 L/minute.10 Such flow rates may be achievable on most flow regulators in EDs by continuing to open the valve, though there will be no calibrated markings beyond 15 L/minute.\nIn both circumstances, to obtain any FiO2 above that of room air, a tight seal must be achieved with the mask, which usually requires a 2-handed technique.13 A bag- valve-mask device hovering above the patient’s face provides only ambient FiO2.\n\n\n\n
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- Apneic oxygenation as described above will allow continued oxygenation but will have no significant effect on carbon dioxide levels.\nThe patients’ mouths being open did not negatively affect the FiO2 provided.\n\n\n
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- Lancet, March 2011\n
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- lower unadjusted mortality compared to placebo despite having more severe injuries\n
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- CCTA - we screen with colonoscopy for something that is more rare than ACS.\nRyan Radecki\n
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