Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Saving Patients from Low Doses of NTG

At EMCrit there is a very important abstract covering the acute treatment of hypertensive crashing heart failure patients. This is a PDF file and it is only the abstract, but it is essential reading for all in EMS and EM (Emergency Medicine).

A Protocol of Bolus-Dose Nitroglycerin and Non-Invasive Ventilation to Avert Intubation in Emergency Department Acute Pulmonary Edema

Results: 41 patients were consecutively enrolled.

Not a lot of patients, but what would be the outcome in a hospital where patients are treated with conventional treatment – the Standard Of Care?

This must be studied in a hospital that follows the Standard Of Care in order to demonstrate just how dramatic the difference is.

I expect that at least half of these patients treated with standard doses of NTG (NiTroGlycerin) and without NIPPV (Non-Invasive Positive Pressure Ventilation) end up intubated.

All patients received NPPV, with initial settings of IPAP 14/EPAP 8.

Remember, some EMS protocols still insist that EMS must never give more than 3 NTG to a patient (and this includes any NTG taken by the patient prior to EMS arrival). The patient took 4 NTG before I got there. I must have violated protocol. 🙄

The mean number of nitroglycerin boluses required was 4, which corresponded to a mean dose of 1588 mcg (range 800-28,000 mcg).

Translated into NTG tabs or sprays that is a range from 2 tabs/sprays to 70 tabs/sprays.

Clearly, the higher doses killed the patients and probably even killed some of their family in the waiting room. These doses are just too dangerous! Think of the children hypotension!

How bad was the outcome?

None (0%) of the patients required intubation (95% CI 0-7.3%).

But that’s impossible!

This is a violation of the Standard Of Care. This is the greatest evil in medicine. Malpractice lawyers will take away everything you own – Twice!

Patients had marked improvements in their respiratory parameters.

This is all wrong. They aren’t supposed to get better with such dangerous treatment.

Two patients had transitory dips in SBP < 100,

That’s more like it.

which resolved spontaneously;

No! No! No!

We have to be the ones who fix the hypotension. They can’t get better on their own. This is just wrong.

Where are the boluses of fluid that we have been told are essential?

Where is the CPR?

Where is the epinephrine?

both of these patients received additional nitroglycerin boluses.

No! No! No!

This is like a C-section. Once something bad happens with a drug, we can never risk that bad thing again. Don’t think, avoid. Reflexively withdraw from the treatment as if withdrawing a hand from a flame. There can never be any safe use of anything as dangerous as fire.

No patients required additional drugs or fluids for hypotension.

Stop it! I’m not listening! This isn’t happening!

You can’t make me think!

Picture credit.

My anecdotal observations on this – Since I started giving higher doses of NTG over a decade ago, I have not had a reason to intubate a hypertensive CHF patient. That is over a decade without access to any CPAP (Continuous Positive Airway Pressure). Zero cases of hypotension. Over 50 sublingual NTG sprays for one patient (potent NTG confirmed after the call).

Yes, I have pestered a lot of doctors about this, but without research it is difficult to convince someone that the patient was looking like death at initial presentation, but is comfortable now.

We need to stop coming up with excuses for intubating these patients and start treating them with high doses of nitrates, preferably IV NTG, but SL (SubLingual) does work.

EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema
by EMCRIT on APRIL 25, 2009
Link to Podcast page

Link to page with other evidence supporting this treatment

.

Hemostatic Resuscitation by Richard Dutton, MD

There is a longer than usual video at EMCrit, but it is worth watching more than once. Dr. Dutton explains about the use of fluids in resuscitation.

Hemostatic Resuscitation by Richard Dutton, MD

We all have our biases. Dr. Dutton does a good job of pointing out those of others, but one that seems to affect Dr. Dutton is the Maryland helicopter system. He does not see that the fly everyone and let ShockTrauma sort them out approach, that was so vigorously defended by Dr. Thomas Scalea, is not supported by any evidence.

After the protocols were changed to cut the flights by about half, there does not appear to have been any change in the outcomes of trauma patients in Maryland.

Dr. Scalea promised us dead bodies galore, but he has not delivered.

It appears that this extreme approach of Dr. Scalea is unjustified, yet Dr. Dutton seems to have unrestricted praise for the Maryland system of flying everyone.

Back to the video. Dr. Dutton points out problems with resuscitation research that has similarly focused only on the extremes –

Unrestricted fluids to keep the blood pressure high (at least triple digits).

vs.

No fluids to allow the body to stabilize on its own.

Dr. Dutton points out that a Goldilocks amount of fluid resuscitation may may exist between these extremes. There are a bunch of studies used to support this. There appear to be big problems with giving too much fluids and with giving the wrong fluids.

We should not be giving fluids that make clotting less effective do not clot or carry oxygen. Updated 08:23 6/12/11.

What do we give in EMS?

Crystyalloids.

What do do crystalloids to to coagulation?

They make it worse.

What volumes do we give in EMS?

Often we give all we can possibly force into any hypotensive patient who is still bleeding. Just to try to make the blood pressure look better. We generally can make the blood pressure look better.

Does this improve survival?

No.

Go watch the video to learn a lot more.

.

Rule Out MI with 12 Lead ECG

We keep reading about cases of medics telling people –

It’s probably just indigestion.

You probably just ate too much chili.

Or some other nonsense.

Maybe someone eating chili should be at the top of the list of cardiac symptoms that get hubristic medics burned.

It is one thing to look at a bradycardia in a young, healthy person and conclude that (in the absence of other symptoms) this is just the healthy vagal tone that is to be expected in young athletes. Even in older athletes.

One of the most important parts of this assessment is that this is a normal heart rate for the patient. Of course, this raises the question of why we are assessing this patient, but sometimes all it takes is a car crash or some alcohol consumption and somebody freaks out because the heart rate is 48.

Yawn.

If that bradycardia is the only thing an assessment turns up, and it is the normal heart rate for the patient, this is not something we are going to make better.

Back to our chili chugging chest pain patient.

Chest pain is not the normal healthy agita to be expected when eating chili. Maybe with some Texas chili.

However, we also need to consider why we are assessing this patient.

Is this normal for this person, when eating chili?

What is different today?

Mr. Agita, do you always call 911 when you eat chili?

If the answer is No, we need to be persuading him to go to the hospital. We do not need to provide him with inexcusable excuses for refusing treatment.

So, why the reference to the EMCrit Podcast?

It is important to remember that this is not sensitive for “MI” which is diagnosed by biomarkers. The lack of sensitivity of the Sgarbossa rule in previous studies is because the ECG is always (even without BBB) insensitive for MI.

EMCrit Podcast 48 – PhD in EKGs Part II: Left Bundle Branch Block

The podcast is about the problem with LBBB (Left Bundle Branch Block) on a 12 lead ECG. We interpret LBBB as new MI much more often than we should.

It is also good to listen to Dr. Smith (of Dr. Smith’s ECG Blog) explain why the research on LBBB is misleading. He explains the Sgarbossa rules and certain modifications he has come up with to improve the sensitivity of the 12 lead ECG in the presence of LBBB.

Going more in depth than the abstract is important in evaluating research. We want to know if the research should be applied to patient care. If it should, then how should it be applied to patient care?

That looks nasty, but is it a STEMI (ST segment Elevation Myocardial Infarction)?

Dr. Smith explains how we should figure that out in the podcast and there information to refer to in the show notes.

What about the quote?

“MI” . . . is diagnosed by biomarkers. . . . the ECG is always (even without BBB) insensitive for MI.

Even in the ED (Emergency Department), the 12 lead should not be used to determine if the patient is having a heart attack. The 12 lead is used to determine if the patient is having a STEMI – an indication of occlusion of at least one coronary artery.

Dr. Smith points out that –

Myocardial infarction includes both STEMI and Non-STEMI. We don’t need to send someone to the cath lab for Non-STEMI. We don’t need to give thrombolytics for Non-STEMI. . . . The majority of myocardial infarctions are not occlusions, . . .

The majority of myocardial infarctions are not occlusions,

The 12 lead ECG is used to identify occlusions (STEMI).

Should we ever consider using 12 lead ECG to tell someone they are not having a heart attack (MI)?

Biomarkers are what we need, such as troponins. Maybe someday chili and ribs and other agita inducing foods will come with biomarker kits (probably something even faster and more specific than troponins and CK-MBs), but we aren’t there yet.

The podcast is the second of two parts. the first part is –

EMCrit Podcast 42: A phD in EKG with Steve Smith

Go listen to both podcasts.

Also read Dr. Smith’s ECG Blog and there are links at the EMCrit podcasts to several specific posts related to these podcasts.

.

What Does it Take to NOT Kill a Patient – Part III


There is a must listen to podcast at EMCrit in combination with Resus.Me. Dr. Cliff Reid is interviewing one of the authors of the study,[1] Dr. Jonathan Benger

EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters

Dr. Cliff Reid – In the ED and the ICU, what are the take home messages for us?

Dr. Jonathan Benger – The take home messages are that as you would expect it’s dangerous and there is a significant rate of complications.[2]

If we do not realize that intubation is dangerous, we should not be intubating.

Dr. Jonathan Benger – What we know is that there were a number of significant events and that the case fatality rate was much higher. In fact it was highest in critical care, and then second highest in emergency departments, and lowest in anesthesia environments. So there is a clear risk of major complications and those complications are more likely to be fatal.[2]

We should expect that the fatality rate for emergency airway management is much higher for EMS, than for anywhere in the hospital.

If we understand that, we should be less aggressive in using methods that take away an airway that allows us to do what we need it to do – oxygenate and ventilate.

Dr. Jonathan Benger – If you undertake advanced airway management outside of the operating theater, you’re working in a difficult environment, where the risks are significantly higher to the patients involved. That means that we need to make sure that the standard of care is as high as feasibly possible in those environments.[2]

The standard of care is not an endotracheal tube.

The standard of care is a competently managed airway that works.

Our patients should not be subjected to a lower standard of care, just because paramedics like to say that we intubate.

Dr. Jonathan Benger – It’s absolutely clear that capnography, as a universal tool in any patient who is intubated, is appropriate.[2]

A bit of British understatement.

Continuous waveform capnography should be mandatory.

Anyone who thinks otherwise should not be allowed to use any advanced airway.

If we cannot afford continuous waveform capnography, we cannot afford to risk our patients’ lives on intubation.

Dr. Jonathan Benger – It’s absolutely clear that if you don’t use capnography, in advanced airway management (intubation, tracheostomy care, et cetera, et cetera) then there is an increased risk to patients as a result of complications. And the obvious one, of course, is unrecognized esophageal intubation.[2]

Maybe I should stop criticizing medics who insist that we should not take their endotracheal tubes away.

The endotracheal tube is not really the problem.

Operator error is the problem.

People too reckless to use continuous waveform capnography are the problem.

These dangerous medics do not want us to take away their unrecognized esophageal intubations.

Dr. Scott Weingart – To pound home what Dr. Benger and Cliff have said. If you are in an ED, or an ICU, or on an ambulance, and you are intubating without waveform capnography – I don’t mean color change capnometry – I mean waveform capnography – you are doing your patients a disservice. This should be standard care for any intubation in the three environments I just mentioned.[2]

Doing your patients a disservice?

Dr. Weingart is not British and is usually a bit more blunt than this.

If we are intubating without continuous waveform capnography, we are killing our patients.

Maybe I will not kill a patient, but I will set an example for someone who will. I am then responsible for convincing others that reckless airway management is acceptable.

How many patients can we kill before we decide that killing our patients is bad?

Not using continuous waveform capnography is reckless airway management.

Even for anesthesiologists.

Listen to Dr. Weingart’s explanation of the possible reasons that there would be no waveform on the display. This is at 16:15 of the podcast.

There is also a discussion of the various forms of crichothyrotomies, needle/cannula vs. surgical. This leads to an interesting debate in the comments with Minh Le Cong, that should lead to a podcast debate about the relative benefits of surgical vs. needle/cannula crichothyrotomies.[2][3]

I will not discuss that here, but I expect to have Dr. Weingart go over that in more detail in a future podcast.

Dr. Benger also describes the problem of continuing to try to intubate when there is no reason to expect that using the same failed method over and over and over and over will somehow eventually lead to a successful outcome. The result –

Can’t Intubate, CAN Ventilate deteriorates to Can’t Intubate, Can’t Ventilate which often deteriorates to death.

We convince ourselves that the goal is a tube.

No.

The goal is an airway that allows us to ventilate and oxygenate.

See also:

What Does it Take to NOT Kill a Patient – Part I – 4/03/2011

What Does it Take to NOT Kill a Patient – Part II – 4/04/2011

What Does it Take to NOT Kill a Patient – Part III – 5/20/2011

What Does it Take to NOT Kill a Patient – Part IV – 5/23/2011

What Does it Take to NOT Kill a Patient – Part V – 5/30/2011

From EMCrit –

EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters – 5/09/2011

From Resus.Me –

Anaesthesia’s dirty laundry – let’s all learn from it – 4/03/2011

Footnotes:

[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

[2] EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters
EMCrit
Podcast and Article with comments

[3] Anaesthesia’s dirty laundry – let’s all learn from it
Resus.Me
Article with comments

.

What if the Best Way to Intubate is Through an LMA

At EMCrit, the topic being covered is the way to intubate through an LMA (Laryngeal Mask Airway) ILA (Intubating Laryngeal Airway), in this case the Cookgas Air-Q, but is an endotracheal tube needed when the device already provides all of this –

Oxygenation.

Ventilation.

Aspiration protection.

Fast.

Accurate.

And provides a route for intubation if a longer term airway is desired.

Audio and video on how to use this are available at EMCrit.

EMCrit Podcast 43 – Laryngeal Airways with Daniel Cook, MD (Part I)

Video for Podcast 43 – Inserting the Air-Q

I used to describe the EOA (Esophageal Obturator Airway) as – A device with all of the complications of intubation and BVM (Bag Valve Mask) ventilation, but with none of the benefits. If you have used an EOA, you may have used less polite words to describe the EOA.

This ILA appears to be the opposite – all of the benefits of intubation and BVM ventilation, but with fewer of the complications.

So, why aren’t we using this in EMS?

This is not just a rhetorical question. I am interested in the possible problems with this airway.

Or, if you are using the Cookgas Air-Q in EMS, what do you think of it?

.

Corrections of Misleading Charts Comment – Part I

In response to Corrections of Misleading Charts, there was this response from Can’t say, clowns will eat me

So, I’m assuming you mean to say that we can actually give unlimited NTG to hypertensive CHF patients? What?!?! But, the NTG will surely bottom out their pressure. We can’t give that. The risks are too great. We need to leave the BP where it is and certainly we’re too stupid to know when it’s hypertension, much less CHF vs pneumonia vs ACS……….

Every day I ask, Mirror, mirror, on the wall. Who’s the most sarcastic of them all. Usually I get a satisfyingly sycophantic response and I go about my ripped from a Charles Adams sketch day. Not so, when this comment appeared. My sarcasm has been slacking. PS Can’t say, when the nice little old lady offers you the apple, go ahead and take a bite. 🙂

So. I have been humbled, but how should I respond?

The comment is perfect.

Furosemide (Lasix) allows medical directors and medics to feel as if they are doing something, but nothing as dangerous as giving NTG.

The irony is that the appropriate use of furosemide (for CHF) is probably a lot more dangerous than NTG, even if the inappropriate use of NTG.

What would be inappropriate use of NTG?

1. Giving NTG to a patient who does not have CHF (or chest pain).

The patient’s blood pressure may drop for a little bit and then recover. If NTG is not indicated, it should not be given, but will this cause as much harm to these patients as the harm we would cause by giving furosemide boluses to CHF patients?

I don’t think so.

Harm from furosemide in CHF?!?!?!?

Yes.

I do not have proof, but there is no good reason for EMS to be using furosemide.

Here is an example of the problem. From the very first EMCrit podcast, very short podcast (10 1/2 minutes), Dr. Weingart says –

It’s not going to help you and it’s very potentially going to hurt you. No Lasix in these patients. Now, I’m sure your EMS providers have already given it. Well, that’s just fine, but you don’t have to exacerbate the problem. Most of these patients will end up volume depleted, not volume overloaded when you look at their intravascular space. You’re probably going to end up giving fluid to these patients, not trying to diurese them. The problem is not fluid overload.

If the problem is not fluid overload, and as Dr. Weingart clearly says –

The problem is not fluid overload.

Then, I have to ask –

Why are so many of us giving a drug just to treat fluid overload?

2. Giving NTG to a hypotensive patient who does not have CHF.

The blood pressure may drop even more. If NTG is going to worsen hypotension, it definitely should not be given, but will there be as much harm to these patients as there would be from giving furosemide boluses to any CHF patients?

I don’t know.

Will there be as much harm to these patients as there would be from giving furosemide boluses to hypotensive CHF patients?

I don’t know.

I don’t expect to see any studies of giving NTG to hypotensive non-CHF patients, normotensive non-CHF patients, or even to hypertensive non-CHF patients. The attitude of the IRBs (Institutional Review Boards) toward medical treatments appears to be, Don’t ask. Don’t tell.

3. 2. Giving NTG to a hypotensive patient who DOES have CHF.

Is this inappropriate?

To be continued in Corrections of Misleading Charts Comment – Part II and in Corrections of Misleading Charts Comment – Part III.

Some of the evidence that supports this –

Prehospital therapy for acute congestive heart failure: state of the art.
Mosesso VN Jr, Dunford J, Blackwell T, Griswell JK.
Prehosp Emerg Care. 2003 Jan-Mar;7(1):13-23. Review.
PMID: 12540139 [PubMed – indexed for MEDLINE]

Free Full Text PDF

Modern management of cardiogenic pulmonary edema.
Mattu A, Martinez JP, Kelly BS.
Emerg Med Clin North Am. 2005 Nov;23(4):1105-25. Review.
PMID: 16199340 [PubMed – indexed for MEDLINE]

Free Full Text PDF

EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema
EMCrit
by Dr. Scott Weingart
Podcast

Supplementary documentation on CHF treatment

.

Medgadget Medical Blog Awards

The Fire Critic is not the only one with blog awards, but he is the only one to have any EMS blogs as finalists.

Polls Are Open in The 2010 Medical Weblog Awards.

The only EMS blog that was nominated was A Day in the Life of an Ambulance Driver, which just happened to win the EMS category in the Fire & EMS Blog of the Year for 2010-2011. Unfortunately, AD is not in the finals.

One of my favorite blogs is in the running for both Best Medical Weblog and for Best Clinical Sciences Weblog.

I first wrote about EMCrit a few months ago in More on Lasix in EMS. Dr. Weingart understands about continuity of care and combines ICU and ED (Emergency Department) care. We need to do more of the same in EMS. How many of us approach patients with the idea that we are beginning the treatment that will be continued in the ED?

Go vote for EMCrit for best blog.

There are several excellent Clinical Sciences blogs, including EMCrit. Since I already voted for EMCrit for best blog, I voted for GeriPal for Best Clinical Sciences Weblog.

The most surprising part of the clinical sciences blog selection is the absence of Life in the Fast Lane.

Some other excellent blogs that should be in the finals for clinical sciences are The Poison Review, Science-Based Medicine, Prehospital 12 Lead ECG, Paramedicine 101, Everyday EMS Tips, The EMT Spot, EMRAP.TV, Dr. Wes, and 510 Medic.

For Best Literary Medical Weblog, there are 2 excellent choices other things amanzi and StorytellERdoc. I can’t tell you which one I voted for, but I can point out that I have 2 computers and let you figure out how I resolved this dilemma.

Some other excellent literary medical blogs are paramedic pulp fiction, Medic999, ER Stories, EMS Haiku, Dr. Grumpy in the House, A Day In the Life of An Ambulance Driver, and Asystole is the Most Stable Rhythm

For Best Health Policies/Ethics Weblog, I am not familiar with any of them, but one that should be there is Gary Schwitzer’s HealthNewsReview Blog.

They also have Best Medical Technologies/Informatics Weblog and Best Patient’s Blog, but I don’t have any familiarity with these blogs.

.

Delayed Sequence Intubation (DSI)

There is a fascinating podcast, although it is not really relevant to EMS in the US, yet. It feels as if this is something that will be part of EMS in the future. EMCrit Podcast 40 – Delayed Sequence Intubation (DSI). There is also a short video (less than 5 minutes) covering DSI and a couple of other airway/preoxygenation topics.

I know. I am a research guy, so why am I going on feelings?

There is a lot of research out there on ketamine, and much more in the works. All of it appears to be producing positive results as far as efficacy and safety. I would be surprised if there is a discovery of some unknown danger.

It is certainly possible that a problem turns up. There have been cases of apparently safe drugs that have been shown to have significant dangers after being used for a while. However, outside the US, ketamine has been used extensively. How extensively? Even EMS uses ketamine. We appear to be way behind the times in doing what is best for patients. Not because it is fashionable. not because others are doing it. Not because it is the cool thing to do. Because it seems to provide a lot of benefits that our current treatments lack.

Ketamine sedates.

Oh no! The hypotension!

Not with ketamine.

Oh no! The respiratory depression!

Not with ketamine.

Oh no! The depressed airway reflexes!

Guess what?

Not with ketamine.

Ketamine is not perfect, but it appears to be a much better drug for dealing with unstable patients in awkward circumstances.

What is more challenging for EMS, than an unstable patient in awkward circumstances?

Where does EMS make a big difference in outcomes? One place is with the unstable patients in awkward circumstances.

In Etomidate in procedural sedation, I wrote about etomidate, which is another drug that is not a cardiac depressant and can be used for sedation under similar circumstances.

When RSI (Rapid Sequence Intubation/Induction) may not be the right thing to do for a variety of reasons, DSI may be the right thing to do. Maybe EMS can use etomidate for these patients, until we finally realize that ketamine is safe and efficacious.

Ketamine does sometimes produce nausea and/or emergence reactions, but in the podcast, Dr. Weingart gives a good reason for not worrying about these with DSI. The nausea only seems to be a problem in a minority of patients and then only on emergence from the dissociative state. These patients would be kept sedated with ketamine for an extended period – at least until after transfer of care in the ED (Emergency Department).

In an earlier podcast on ketamine, Dr. Weingart explained that he thinks that the problem with emergence from ketamine sedation is similar to the problem with bad LSD (Lysergic Acid Diethylamide – LSD, because Acid is Saure in German) trips.

Should the answer be DSI?

I think that this is coming to the more progressive systems, but another way of using sedation with ketamine (or etomidate) may be to use DSA (Delayed Sequence Airway). Why does airway control need to be with intubation?

It doesn’t.

This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight. The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation. The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.

Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]

The sad thing is that this may still be a novel approach to prehospital airway management almost 4 years later.

But there is a YouTube about it, so how novel can RSA be?

The YouTube is from the medical center where Dr. Braude and Dr. Richards work. When others are doing RSA, then RSA may no longer be a novelty.

Does an extraglottic airway mean increased aspiration?

Maybe not. If we work on ways of monitoring the airway, we may not have any greater incidence of aspiration with extraglottic airways than with intubation. If we become comfortable with extraglottic airways, we may even find that we have a lower incidence of aspiration with extraglottic airways.

What about DSA (Delayed Sequence Airway) with CPAP (Continuous Positive Airway Pressure)?

Why not?

But the patient has to be fully alert for CPAP.

Maybe we will be able to write some more flexible protocols for CPAP and EMS. We are still not using CPAP enough to become as familiar with it as we will need to for innovation.

If you have not done so, yet – Go listen to the podcast.

.