Here it is, the first of January and 2018. FOAM grabs galore, ranging from POCUS, to papers, to Blogs, sites and infographs.

What you see here are the best of what I have found over a very busy January.

If you didn’t see our article on BNP, check it out here.

I was helped along with this one…from a hopeful little Critical Care Doc in the making, Finley (Born 7th January). Here’s hoping he has more patience than me!

Sad we can’t get to the fantastic Critical Care Reviews meeting 2018, but we will be featuring Rob’s book tomorrow.

Next meeting, CCS Manchester. I feel privileged to be a part of the faculty at this jam packed Crit Care meeting. You can book it by clicking here.

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All the best and onward…..

JW 18th January 2018

Blogs!

Troponin…the pain in the a**e of ITU!

emDOC’s put out a brilliant piece on other causes of raised troponin aside from AMI.

Don’t let them blow!

FOAMfrat take us through the safe transport of raised ICOP patients…lovely piece!

ARDS…we got it all wrong!

The crew at PulmCrit take us through the pitfalls of the Berlin definition of ARDS in a rather eloquent manner. Must read!

Time isn’t everything!

Josh Farkas talks through the fallacy that is time to intervention based studies. When you read through it, it makes you think hard about some of the ‘amazing’ data that have been released pressuring us all to ‘do the right thing’ and be swift. But maybe those are for the wrong reasons!

Sites!

NEWS-2 coming to you!

As we said a while back…it’s here, but will it lessen the burden of sick patient identification? You can go and get certified here now….

The Vortex is where it’s at!

This is a nice visual on how to keep yourself out of deep water when intubating…novel and clear!

Articles!

The European Resuscitation Guidelines have been renewed!

ART scuppered recruitment manoeuvres!

ART was released and we all started to fear the effects of excessive RM’s on our ARDS patients as they were potentially increasing mortality. But…this editorial challenges the ART statements. Read on.

CAP…treat it in the ED

A nice little update if nothing else here.

That fear of proning!

APRONET told us so…the infogram below denotes it as well…but this editorial chats through why.

Landiolol…heard of it?

Treatment of AF on ICU is controversial…particularly when w ego ploughing in with Beta blockers. But, maybe we can breathe a bit as Landiolol could be a lovely short acting alternative?

Restrict…all the time though?!!

Perhaps critical care patients Vs the surgical population are a tad different when we actually restrict packed RBCs. It has been shown to be of overall benefit to the ICU population…but what of the general surgical population?

Should we be chasing the procalcitonin driven cessation!?

So should your lab start offering this test so you can rationalise your antibiotic therapy? We know it may lead to a shorter more appropriate therapy course…but did the use of PCT guidance have a mortality benefit…it WAS too difficult to know until this mate-analysis…

Chase high…chill a bit!

Are we doing more harm chasing higher MAP targets in sepsis….we are recruiting into the 65 Trial as we speak. This meta-analysis may answer the question 65 may reveal….

WOW…don’t hand over then!!!?

We tend to focus on the ‘silence and listen to me when I am speaking’, style of handover of our anaesthetics. What is confusing here and needs clarification, is whether this is intra-op anaesthetist to anaesthetist, or from anaesthetist to recovery?? Read on though…could over-detailed handovers be a bad thing then?

Focus on the POCUS..of the diaphragm!

We should pay more attention to diaphragm atrophy, as there is an ever increasing evidence base telling us it has an impact on liberation from the ventilator. So..POCUS it!

Antibiotics ‘Willy nilly’ in OOHCA may be pointless?

28% aspirated in the group, which is no great surprise, but even if they didn’t was there any point in anti-bugs? They looked, and found…well…read on

Should we intervene in sepsis then??

This has been a bone of contention, certainly in hyperthermic states with sepsis. We published on this briefly in the JICS. The CASS trial was futile, as in the hypothermia group, 44·2% died within 30 days versus 35·8% in the routine thermal management group. The cohort did not have hyperthermia and had respiratory failure at entry though…bare that in mind. A no no then!

More advanced volume status assessment!

A great concept, combine a load of parameters and ultrasound measurements and hey presto…possible better correlation with IVSA? Complex though…

They looked at:

Heart
- Hyperkinetic=-1
- Normal=0
- Hypokinetic=+1
Lungs
- Absence of B-Lines=-1
- 1-2 B-Lines=0
- 3 B-Lines=+1
IVC
- < 2.5 cm and > 50% respiratory variation in diameter=-1
- 1.5-2.5 cm
- < 50% respiratory variation = 1
- > 2.5 cm and < 50% respiratory variation = +1
IJV
- > 40% respiratory variation = -1
- 20-40% respiratory variation = 1
- < 20%=+1.

Look at the rSO2 after cardiac arrest…didn’t think of that one!

Worth a thought this…regional cerebral haemoglobin saturation and recovery of neurological function after ROSC.

HYPERION trial is coming!

So shockable rhythms benefit from cooling…what about non-shoakcble?? Lets see…

All about the clock!?

As mentioned above from Josh Farkas, this article summarises the potential windfalls we may gain in expeditious treatment, in particular, with the 3 hour bundle for sepsis. But, as above, are we being over pressured?

Surely not!

Neostigmine reverses neuromuscular blockade, but there are instances where it can actually cause weakness…counter-intuitive to it’s aim! This trial investigates that phenomenon using saline as a placebo Vs Neo when TOF is at 0.9.

CIN is a sin!

Rather a nice overview of CIN…we see a lit of this but this is more of a visual representation.

Why oh why aren’t we proning!?

A nice editorial regarding the fact we perhaps aren’t singing from the same song sheet.

Also see the APRONET study

Fat, Carbs…what the hell!?

Rather a nice piece from Aseem Malhotra in Men’s Health this week regarding a lot of controversy over dietary myths…worth a look!

POCUS Stuff!

The original gangster!

Here is one of the original seminal articles bringing all the chat about B-lines together for us. Thanks to @iceman_ex for this

Make scanning kids a cinch!

Nice piece there from AliEM

A beautiful funnel

Blood through the LVOT seen as a funnel.

Fall from your bike…look at the spleno-renal space!

Thanks to J Christian Fox again for this.

Massive LV thrombus!!

Stabbed…almost to death!

LUNG POINT (pathognomonic for pneumothorax) and decreased lung slide at the apex. CXR WAS NORMAL. CT confirmed a generous pneumothorax. Thx to the POCUS Atlas for this.

So simple…B-line analogies!

Thanks @ultrasoundpod

and from @constirusu…

Watch it…there may be trouble ahead!

Oops…L Atrial haematoma after a Cath!

Sludge looks like liver!

Thanks to Dallas Halliday for this…the stones are the eventual giveaway.

PE…look for that sign!

Here’s McConnel’s again…

Liver and more liver!?

EMUSS show us what hepatized lung looks like.

CVP in…look on echo!

J Christian Fox shows us the bubbles!

Want to find the appendix?!

Stephen Alerhand shows us!

Kicked by a horse!

@docmagic shows what POCUS heralds before CT and theatre!

Scan when you can!

US Alberta remind us of the potential throbbing things we might puncture when draining ascites! Watch it and scan first…the last thing you need is a bleed in a patient with a defunct liver!