EM:RAP and Pharmacy of Airway Management (September 2018)
AIR: Pharmacology of Airway Management
EM:RAP for Asynchronous Learning! For credit, first, listen to the entire podcast. Your participation in the discussion board here is your attestation that you have listened and engaged with the content in a meaningful way.
When you have finished listening to the podcast, answer the following questions:
- Please list three things you learned from this podcast that you were not aware of before.
- Are there any areas of your practice that you would change after listening to this podcast? If so, what would you do differently?
- What topics mentioned in this podcast is considered too “bleeding edge” (ex. too new, lacks enough evidence, not ready for prime time). Are there any practices mentioned in this podcast that you would consider to not be applicable to our practice setting here at BMC?
5 comments
1. I’m was not aware that this month represents the 50th anniversary of Emergency Medicine in the US. I did not realize why a distinction has been made between unstable angina and coronary artery disease – We are approaching a truer understanding of the actual disease process. Was not familiar with the SOAPME acronym (although in reality I would never forget these, of course): suction, oxygen, airway, position, medications for RSI, etCO2.
2. I like the idea of airway dump-kits. Dan has created these for us here at BMC, Thanks Dan! Like the idea of BVMs already hooked up to O2 and flowing when you pick it up. I do not think I will be using the etO2 to evaluate for quality of pre-oygenation, just seems like another layer to add on to an already busy situation. Can you not just correlate the quality of your pre-oxygenation with your O2 sat which you will have on the patient’s finger anyways?
3. Things that may be too “bleeding edge ” for BMC include femoral nerve block or fascia iliacus block for hip pain in the context of hip fracutre. Ortho would not like it as it would muddy their examinations – not a valid excuse for protesting a nerve block. We do not have enough attendings who are comfortable with these to supervise. We are not staffed in a way where this could work for many patients due to the fact that these procedures take time to perform well. I’m not sure how comfortable people will be giving people high doses of suboxone in the ED to lengthen the window of safety before withdrawal sets in. I also feel that standing doses of antibiotics would not work well in our ED with the current staffing and volume levels. We are barely holding dosing together now as it is. We are not equipped to deal with ongoing care.
1.
I did not know that 25+% of STEMIs did not receive intervention. I agree that the current NSTEMI v STEMI paradigm does not work, especially when it is not clear how to classify NSTEMI (type 1 v 2), since this comes down to more than simply the level of troponin peak, and peak can take 24 hrs.
No difference between PO and IV steroids, given the suprahuman dosing of IV steroids, give PO if you can
IDSA recommends against steroids routinely for pharyngitis
2.
I would use buprenorphine in the ED, especially for patients in withdrawal needing further work up or admission. Given the limitations of how we give methadone in the ED, I think this is particularly important and useful.
3.
Fascia iliaca blocks are a great idea, but they seem like something we cannot do as of now due to ortho’s limited use of blocks in general. This would be nice to move forward given all of the risks factors of opioids in the elderly (especially demented). With ultrasound, the structures are generally clear and it’s a safe block.
1. – ST segment elevation is different in men and women 2.5 for men under 40, 2.0 for men over 40, 1.5 for women, This makes peds EKGs really tricky because a lot of ST elevation is actually early repolarization.
– only 30% of posterior STEMIs go to cath. 4-5% of STEMIs are isolated posterior. 20% of STEMI are diagnosed subsequent EKGs so always repeat EKG if you are concerned
– IV steroids are not better than PO unless your patient cannot swallow or keep them down for any reason. A higher dose is not necessarily better. And check your indications for steroids – it isn’t a harmless med.
2. I would like to try more nerve blocks in the ED and it would be great to see if we could do that for pain in lieu of opioids for pain control on extremity fractures, especially straightforward hip fractures. I had a hip fracture transfer the other day who was old and frail (no surprise) and got snowed by the opioids I gave her. I’m wishing I had a better idea of how to control her pain without affecting her mental status so that she would be more awake for a real trauma eval.
3. I’m a little confused, I thought we send patients home all the time on oxycodone because it’s less habit forming, but this tells me it is one of the more habit forming drugs. It seems most of my attendings like to use oxycodone as a first line for po opioid in the ED and if we send people home with a few pills.
1.) Buprenorphine. They did a really great segment that convinced me how much of an asset this med can really be. I look forward to getting my waiver and being able to provide the bridge therapy.
2.) the human factor segment on resuscitation. I think this is a great piece that all new PGY2s such as myself can benefit a lot from as far as team leadership, maintaining control of the room, etc.
3.) Steroids. I will be re-examining how I use steroids and will be going back to the primary literature as I have perhaps become one of the steroid over-prescribers they are talking about. It is good to know there is no benefit for a significant number of the “indications” we are routinely using for in the ED
1. I knew that big pharma was bad, but I did not realize the extent to which they altered their data. That segment was concerning enough to turn me off from trusting ANY pharma backed study, even a little. Have a much better understanding of buprenorphine and how we can use it in the ED. Most of all I really liked the OMI discussion. Had no idea that 25% of OMIs were missed by STEMI criteria. I think this paradigm shift should happen and hopefully soon.
2. I am going to treat with steroids much differently now. I knew the IV vs PO thing, but so many of the “indications” for steroids are actually not founded in data! I thought that was a particularly useful segment. I will also be much more suspicious of an OMI if the pt clinically appears to be having an MI–regardless of the EKG findings.
3. Fixing the EMR to account for abx dosing is too bleeding edge. We aren’t there yet and doubt that will come for a while. Also, while I really like the OMI paradigm, I’m not sure that will take off for a while. Activating the cath lab is such a rigorous and pre-defined algorithm that it will be hard to change.