I gave 2 talks at the North York General Emergency Medicine Update this year. These are the resources for these talks. Usually, these resources are only for conference attendees, but this year I recorded versions of both talks, so you can watch them even if you didn’t make it to Canada’s premier emergency medicine conference this year. Enjoy.
RSI and then they die
When patients come in critically ill, we have lots of excuses. They were sick before we got to them. The outcomes are easy to rationalize. However, the truth of the matter is, they were alive before we decided to intubate, and now they are dead.
Although I believe we have been improving since I started practicing emergency medicine, statistics tell us that peri-intubation cardiac arrest is still a common occurrence in emergency medicine and critical care. This talk considers the 5 high risk scenarios for “RSI and then they die” and what we can do to prevent that outcome.
The check list I use for predicting peri-intubation collapse is:
- What is the patient’s oxygen?
- What is their blood pressure (and shock index)?
- What is their respiratory rare (ie, could this be metabolic acidosis)?
- Could this patient have RV failure?
- Is there bronchospasm?
That check list will help you identify almost all patients who are high risk for peri-intubation arrest. Before every intubation, just remember to pause and ask:
- Is this patient ready for intubation?
- Is RSI the best approach?
Because we were trained on the ABC model, airway always feels like a priority, but remember it is often a better idea to resuscitate before you intubate.
More resources:
The FIrst10EM airway series:
Pulmonary hypertension and right ventricular failure:
Most interesting articles of the year
There are obviously a ton of papers published every year. I gave a longer version of this talk earlier in the year, but with just 15 minutes, I focused on the 8 most interesting papers of 2023, meaning a few big trials like UK-REBOA, PATCH-TRAUMA, and CRYOSTAT-2 got cut. These are my selections:
Steroids for community acquired pneumonia (CAPE COD and ESCAPE)
Bottom line: Be cautious about indication creep and patients with influenza, but this seems to be practice changing, and we should be prescribing steroids to patients with community acquired pneumonia who require ICU level of care.
Fluids in sepsis (The CLOVERS trial)
Bottom line: The CLOVERS trials is an open label RCT that did not demonstrate any difference (either beneficial or harmful) from using a restrictive fluid strategy over a liberal fluid strategy in sepsis induced hypotension. Clinical judgment is important. Vasopressors might ensure your patient gets the ICU level of care they deserve.
Video versus direct laryngoscopy (The DEVICE trial)
Bottom line: This trial was positive for its surrogate primary outcome (first pass success), but showed no difference in the important clinical outcomes. Despite that, I don’t think you really need science to know that video is better in most situations.
Delayed sequence intubation (Bandyopadhyay 2023)
Bottom line: This is the first RCT of DSI, and the results clearly favour DSI. However, it is a very low level of evidence, being an unblinded single center study, with multiple sources of bias. I think that it is reasonable to use DSI, and I think that all emergency providers should be familiar with DSI, but this does not make DSI the standard of care.
Push dose keppra (Summerlin 2023)
Bottom line: In a small, single center observational cohort, keppra looks relatively safe when used as a push dose. In a true status epilepticus patient, I think it is reasonable to push keppra. For everyone else, I will continue with the standard infusion.
Contrast doesn’t hurt kidneys (Ehmann 2023)
Bottom line: Focusing specifically on the highest risk patients (emergency department patients with evidence of acute kidney injury), this very large propensity matched trial found exactly no association between receiving IV contrast and kidney outcomes. There are lots of reasons to be cautious about overusing CT, but IV contrast is not one of them.
https://first10em.com/research-roundup-april-2023/
ED boarding kills patients
Bottom line: This retrospective cohort demonstrates an association between overnight boarding in the ED and increased mortality among elderly patients. Although one observational study doesn’t mean a lot, there is decades of data showing the same. Of course, we don’t really need this evidence. It is absolutely inhumane to force sick elderly patients to sleep overnight in hallways in the emergency department. It is disgusting and it needs to stop.
2 thoughts on “NYGH Emergency Medicine Update 2024”
As always a great review on the subject of RSI
Instead of using the expensive NIV-masks I would suggest using the standard BVM mask that is equipped with a ring with 4 hooks (the rings are sold separately as well if your masks come without them) and use cheap reusable mask straps.
You can now provide CPAP hands-free if you add some corrugated tubing in combination with the BVM+PEEP valve+NC+ ETCO2 setup or you can provide either CPAP or BPAP if you hook the patient up to a standard ventilator set to NIV mode (which all but the most basic of ventilators have these days).
I would advise great caution against using the dedicated NIV machines for this as some models require special masks where the exhalation port is fitted into the mask itself. But since you were planning to intubate the patient anyway why not use the regular ventilator from the getgo for simplicity and to avoid wasting masks and tubing.
You can also use the mask in combination with the vent (not set to NIV but to AC mode now) for reoxygenation if your first attempt at intubation would fail.
This has also been advocated for by Scott Weingart and Jim DuCanto in these videos:
“RSA to RSI by Jim DuCanto” and “initial output” (latter part of the video) and “Vent as a Better BVM” on the EmCrit YouTube Channel.