This is another quick trawl of the best of FOAMed. I am delighted to announce that I have teamed up with Jonathan Downham (@ccpractitioner), to bring you the ‘2 Jonnys’ podcast every fortnight.

Check out his brilliant work here:

We will discuss the best of FOAMed as an accompanying podcast to the blog. So as they say, read along and listen as you go! Podcast available below:

The Official 2 Jonnys Podcast – Episode 1

Slate the scores?!

More on qSOFA / Sepsis 2 and Sepsis 3 here. Really well put together piece from the rebel EM crew. Click the pic.

Bottom Line: Among adult patients with suspected infection admitted to an ICU increase in SOFA ≥2 had greater prognostic accuracy for in-hospital mortality than SIRS and qSOFA

Bottom Line: qSOFA had a greater prognostic accuracy for in-hospital mortality than did either SIRS of severe sepsis, and although this is an important endpoint, it does not help with screening for those cryptic septic patients in the ED.

Clinical Bottom Line: Neither score is perfect. On one hand, Sepsis 2.0 has a better sensitivy for screening but at the cost of specificity as so many other things can cause SIRS. On the other hand, Sepsis 3.0 has a better specificity for prediciton of mortality when compared to Sepsis 2.0, but there maybe other scores out there that may do a better job.

The Canadians got it right!

Have look at the Canadian CV Society guidelines on the optimum care of the post arrest patient. Give us food for thought. Click the link to download and have a look through. DO you do the right thing?

Don’t rely on drugs…’Vec-Off’ and be prepared!!

In an emergent situation, don’t count on sugammadex to rescue a paralyzed patient from a “can’t intubate, can’t oxygenate” scenario. This nice little vignette and podcast discussion should be a warning to all of us. This pricey drug may not save your bacon! Or the patient…or your department’s budget!!

You absolutely can’t give O2 to COPD patients…seriously!

Great article here which partially explains what happens when we pipe in high FiO2 to COPD patients. Also some great reminders of how potent HPV can be…and I don’t mean the HPV associated with gynae problems!

Fluid Resus for Sepsis…PLR / IVC…crikey!?

Haemophilia…remember that Bleeder!?

A great article here reminding us all about this condition and a great little recap on the clotting cascade involved too…well at least this weeks clotting cascade!!

Their take home points..

Deficiencies in clotting factors (secondary hemostasis) tend to cause deep bleeds (i.e hemarthroses, deep muscle) vs superficial bleeds (petechiae, purpura)
Hemophilia typically has a prolonged aPTT (Intrinsic pathway – Factors VIII & IX) but normal PT (extrinsic pathway – Factor VII)
The mainstay of treatment for hemophilia remains replacement of deficient clotting factors (Always try and use what the patient is on as a first choice)
If a patient does not know their factor level, assume it is 0%
Mild to Moderate bleeds should have their factor replaced up to 50%
Life threatening/severe bleeds should have their factor replaced up to 100%

Difficult IV…go for easy IJ?!

This article delineates how to obtain IJV access in a rush / when all else has failed. Most of the time the IJV is more than scannable, even in the case of a severely dehydrated patient….so why not place a safe, temporary cannula into it….done!

MAP may be out!

We seem to consistently and persistently chase MAP as a guide to what we think may afford optimal organ perfusion. But are we chasing a lame dog!? Various papers have found no real mortality benefit in chasing higher values above 65…as in the one below:

This paper is interesting, as the authors looked at a range of other parameters including echo findings, mean perfusion pressure (MPP) and diastolic perfusion pressure (DPP) to name a few! These were seen to fluctuate quite markedly and could be linked to those that succumbed to AKI, Vs MAP which didn’t seem to correlate!

More on fluids…do they wreck the kidneys?!

Another interesting article discussing the role of overzealous fluid replacement on kidney function in critical illness.

This all fits in with what Manu Malarian states regarding the kidneys and fluid overload…

Good Old Troponin..again!

Measuring at the wrong time, for the wrong thing and with low positive predictive value! This test is the ‘mirror, signal, manoeuvre’, test for chest pain. It is also associated with other extra-cardiac conditions! Read on….

Aspirin…cures pain, unsticks platelets and the bugs hate it too?!

Seems salicylic acid may really get to S. aureus! It may all be due to the fact that it really hampers then fibronectin structure of the bacterial cells and the rest! SO it could just be the agent we might consider in combination with antimicrobial therapy in endocarditis! It may even reduce short term mortality in CRBSI!

POCUS!

It might not be BSE…but FICE will do for me!

So we all try our best to become FICE accredited, but its a relatively hard trot! If you are regionally mentor’less, you are kind of stuck at 1st base. But, becoming BSE accredited is a marathon! This article beautifully outlines the fact that a good FICE scan goes miles for your patient!

Screen Shot 2017-05-05 at 16.27.27.png — Interesting to see the primary indications for FICE echo.

The Right heart…a right bugger!

Are you any good at RV strain / RVH and causes of…please take a look at this fabulous 5 minute soon video tutorial regarding the ins and outs of the RV!

Is the IVC out for fluid responsiveness?

Well…not entirely, but we have to be very careful when looking at collapsibility index in the mechanically ventilated patient. Some forget this, as well as the fact that your ‘sniff’ collapse in SV patients is reversed in MV patients…Inspiration = expansion in MV, Collapse in SV. More studies need to have 100\5 faith in the IVC it seems.