Resus Tonight - Critical Care and Emergency Nursing (Resus Tonight)

We welcome back Nicole Cook, APRN and CNS to talk all about sepsis... and Nicole shares a personal story about sepsis we won't soon forget.

Introductions to Allan, Rob, and the Resus Tonight vehicle. We're most active on Twitter @ResusTonight.

The intubated, altered neuro patient waiting for an ICU bed in your ED can be daunting. Here we talk about the best ways to examine, trend, recognize, and communicate your findings to your team.

• Components to one method of neurological exam
• The pitfalls of the Glasgow Coma Scale
• Brain anatomy in ICP

Are you looking for pathology beyond a STEMI when ordering and interpreting a 12-lead EKG? In this episode we introduce you to other patterns you should look for, especially in the undifferentiated patient presenting with a suspicious story. We'll have you quoting Sgarbossa, Brugada, and AvR pathology in no time!

• Sgarbossa - https://litfl.com/sgarbossa-criteria-ecg-library/
• Brugada - https://litfl.com/brugada-syndrome-ecg-library/
• AvR Stemi - https://litfl.com/lmca-occlusion-st-elevation-in-avr/

This is part 1 of 2 with our friends Landon and Monique from the NursEM podcast where we about common legal, regulatory, and advice for documentation. 

• Does charting MD aware absolve you from responsibility?
• Does charting will continue to monitor actually mean anything to a nursing legal expert and a regulatory body?
• How is the regulatory college of nurses different than the legal system?

Find the NursEM podcast at http:///www.nursem.org or on Apple Podcasts, Google Play, and Spotify.

---
Twitter: @ResusTonight

This is part 2 of 2 of our interview with Landon and Monique from the NursEM Podcast.

---
Twitter: @ResusTonight

If you aren't using waveform capnography where appropriate, you are not evaluating ventilation and gas exchange properly.

It is a highly reliable way to evaluate CPR effectiveness and return of spontaneous circulation

• It can also be used as a prognosticator for cardiac arrest
• Capnography is probably the single most useful tool for monitoring patient status during procedural sedation
• Waveform capnography can be used as a marker of metabolic assessment

In our experience, nurses get little to no education on cognitive bias in their bachelor's degree  program. For a review of anchoring bias, click here.

Allan shares a clinical experience where he anchoring bias can affect patient care. 

Alpha, beta, V1 and V2 receptor goodness is talked about in this episode. This episode also features Allan turning into The Rock.

• Inotropy means increased myocardial contractility
• Chronotropy means increased heart rate
• Vasopressor means squeezing of the blood vessels
• Scott Weingart (reference below) coins a term Inopressor, where some drugs cause all of the above – one such example is epinephrine
• Alpha 1 receptors are found in the periphery and are responsible for vasoconstriction
• Alpha 2 receptors are in the periphery and are responsible for vasodilation
• Beta 1 receptors are primarily in the myocardium and cause ino and chronotropy
• Beta 2 receptors are in the lungs and result in bronchodilation
• V1 receptors are in the blood vessels
• V2 receptors are in the kidneys

In this episode, we explore the RENOVATE study, comparing high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV or BIPAP) for acute respiratory failure. Discover the pros, cons, and practical takeaways for using HFNC in the ICU and ED. 

Rob recounts the story of his first traumatic cardiac arrest as a paramedic. 

•  CPR doesn't make sense in a traumatic arrest where hemorrhagic and obstructive shock are the suspected etiology
• A 'three hole punch' are bilateral finger thoracostomies and a pericardialcentesis is one way to decompress the chest in blunt traumatic cardiac arrest
• The nurse's role is to ensure a shared mental model once the patient arrives so that CPR is started and/or stopped

Evidence

• PMID 29177620
• https://resus.org.au/download/section_11/anzcor-guideline-11-10-1-als-traumatic-arrest-27apr16.pdf&ved=2ahUKEwiczvjHitnkAhXFvJ4KHSvNCfEQFjALegQIARAB&usg=AOvVaw2ztgUJeIvyARaNjrCTrBRv

Do ED ICUs save lives? Probably.

The paper in question is by Gunnerson et al and can be found here.

Scott Weingart's work on ED ICUs can be found here. 

Allan and Rob travelled to Philadelphia for the ResusX and MedED Evolved Conferences.  Philly cheese steaks were consumed, learning occurred, and podcasts were made.  

The next few episodes will be a mini-series recorded with some new friends from ResusX and MedED Evolved!

Allan and Rob have the privilege of sitting down with Salim Rezaie of RebelEM to talk about cervical spine collars and backboard in the ED.  RebelEM has has already extensively covered the evidence on collars and backboards. You can find their blog posts and links below.

1. Spinal immobilization in trauma patients
2. Cervical spine evaluation and clearance in the intoxicated patient
3. Stiell et al. (2018) - A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses
4. Skeptics Guide to Emergency Medicine - Ep 232 - An overview and literature evaluation of cervical spine collars and an appraisal of the above paper
5. Dr. Ken Milne and Alison Armstrong filmed a news clip on the 2018 Stiell et al. paper for us at NENA 2019. 

We had the opportunity to present The Nurse Led Code and facilitate a Code Choreography workshop to the attendees at ResusX. Needless to say, it was a humbling to learn alongside the curious, bad ass physicians that attended.

We even had the chance to talk to Scott Weingart about The Nurse Led Code which was pretty cool, given that his podcast was the first place we heard of it.


References

The fun piece of The Nurse Led Code is that it hasn’t had direct, published data. So, if you’re a nurse looking for a research project, I recommend you look at this setup!

Click here for our references.

Allan and Rob's final ResusX Series Podcast where they talk about the Zero Point Survey and its place in the resus room with our friends EM Centered (emcentered.com) and Salim Rezaie (rebelem.com). 

Zero Point Survey further reading-

• Cliff Ried's Paper - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166036/
• EMCRIT's post with Cliff Ried - https://emcrit.org/emcrit/emcrit-wee-zero-point-survey-video-by-cliff-reid/
• St. Emlyn's blog post - https://www.stemlynsblog.org/jc-the-zero-point-survey-optimising-resuscitation-teams-in-the-ed-st-emlyns/

Nyssa from The Q Word Podcast is on the show to talk about the one thing we should be practicing the most: Resuscitation Langauge, coined Resuscitese.

References

• https://www.jpeds.com/article/S0022-3476(14)00878-6/fulltext
• https://emcrit.org/wp-content/uploads/2016/06/Improving-Verbal-Communication-in-Critical-Care.pdf
• https://emcrit.org/emcrit/learning-speak-resuscitese/
• https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201412-552PS   (particularly the sections titled “Ask the Other Clinicians Present for Input,” “Stop Resuscitation Efforts” and “Explain What Has Happened to the Family.” 
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278143/

Allan and Rob talk about learning in the clinical environment.

Main topics - 

• The relationship matters
• Intentionality in clinical conversations
• What's the yield on your clinical questions?

Some interesting papers - 

1. Eva, Kevin & Regehr, Glenn. (2008). “I'll never play professional football” and other fallacies of self-assessment. The Journal of continuing education in the health professions. 28. 14-9. 10.1002/chp.150. 
2. Eva, Kevin & Regehr Glenn. (2007). Knowing when to look it up: a new conception of self-assessment ability. Academic Medicine : Journal of the Association of American Medical Colleges. 2007 Oct;82(10 Suppl):S81-4. DOI: 10.1097/acm.0b013e31813e6755
3. Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry
   Rudolph, Jenny W. et al. Anesthesiology Clinics, Volume 25, Issue 2, 361 - 376

The show page is found here.

Allan and Rob have the privilege of having a chat with Alin Gragossian about the days before her illness, heart transplant, and return to her work as an emergency medicine resident.

Follow Alin!
Website - https://www.achangeofhe.art/
Twitter: @ag_em33
Instagram: @a_change_of_heart_blog

We are pleased to have the trailblazer Tammy Lowe and THE Korbin Haycock on the show to share their amazing Nurse Point of Care Ultrasound program, one of the only programs in the world (to our knowledge - please correct us if we're wrong... we'd love to learn more!).

Their Nurse Point of Care Ultrasound program was published in the Annals of Emergency Medicine in 2017. The link to the paper is HERE.

Tammy is a boss level Registered Nurse and the Clinical Administrator for Critical Care at a large hospital in California. Find Tammy on Twitter HERE @TammyLowe357

Korbin is an emergency physician and the definition of a resuscitationist. Find him on Twitter HERE @KHaycock2

This podcast was recorded on March 13, 2020. The content of the podcast may change as new information becomes available. Always check with your local resources and sources with credible references.

One of the places resuscitation begins is at the front door. In this episode we provide practical tips for nursing care for patients with suspected or confirmed COVID-19.... in fact, this information could be generalized to all patients with undifferentiated dyspnea.

The Internet Book of Critical Care is a living resource for COVID-19.

REBEL EM has an excellent look at COVID-19 

In our COVID-19 Critical Care series we are hitting you with the fundamentals of critical care that you may need when caring for COVID-19 patients. 

In this episode we cover non-invasive positive pressure ventilation and continuous positive airway pressure ventilation. 

References

• Keenan, S. et.al. (2011). Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. Canadian Medical Association Journal. PMID: 21324867
• Nee, P. et.al. (2010). Critical care in the emergency department: acute respiratory failure. Emergency Medicine Journal. PMID:  21112972
•  Caples SM, Gay PC. Noninvasive positive pressure ventilation in the intensive care unit: a concise review. Crit Care Med. 2005;33(11):2651–2658. 

Sara, ICU RN is on the show to share her firsthand experience battling severe COVID-19. She shares what she has learned, tips to get you prepared, and touches on the human side of caring for the sick COVID-19 patients.

Resources

ARDSnet - http://www.ardsnet.org/
University Washington Medicine - https://covid-19.uwmedicine.org/Pages/default.aspx
Nicole Kupchik, CNS - https://www.instagram.com/nicolekupchik/?hl=en

The CDC recommendation for homemade masks has lit a firestorm among health care providers. In this episode, we give our take on the recommendation. We also break down some interesting data on disease transmission.

AS ALWAYS, READ THE PAPERS AND COME TO YOUR OWN CONCLUSION.

References

CDC. Strategies for Optimizing the Supply of Facemasks. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html

Doremalen, N et al. NJEM. https://www.nejm.org/doi/full/10.1056/NEJMc2004973

Ong et al. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2762692

Pyankov. Journal of Aerosol Science. https://www.sciencedirect.com/science/article/pii/S0021850217302239?via=ihub

We are proud to be project managers for (as far as we know) the only international, free, open source nursing course with the sole intention in fighting COVID-19.

covid19.epicclearning.ca

Authors from Canada, USA, United Kingdom, Italy, Belgium, New Zealand and Australia have volunteered to help support nurses caring for patients with COVID-19.

We recorded a podcast this week to give you more background if you'd like to hear.

This episode features two brilliant guests: Nick and Hussein. Nick is a husband and father. He also has cystic fibrosis and is a double lung transplant recipient. 

Hussein is an ICU and emerg doc with specialty in ECMO. His ECMO team helped bridge Nick to his transplant.

Listen to their experience!

For better or worse, Allan and Rob are reunited as they rehash some of the early COVID-19 literature and scientific direction for ED and critical care nurses.

Today Allan and Rob get the opportunity to talk to the one and only Nicole Cook.  She's a trauma nurse specialist, neurotrauma expert, and a great Twitter follow (@TraumaSoapBoxes).  This episode is part 1 of a 2 part series on neurotrauma nursing care in critical care environments big and small. 

Allan and Rob continue the conversation with Nicole Cook about neurotrauma. If you haven't listened to episode 26, part one of this conversation, then we suggest you go back to do so.  However, we wouldn't recommend listening to us anyway. 

Nicole's paper on Co2 - https://www.injuryjournal.com/article/S0020-1383(21)00624-0/fulltext