We're back with another Last Week Now. Btw, did you know that we are closing registration for the ResusX:ROSC conference in a few days? If you were thinking of going, now is the time to register. Now, let's see what we were up to last week. :
- Why bicarb pushes just don't work
- Should we ditch direct laryngoscopy for video?
- Demystifying chest tubes by Tarlan Hedayati
- A great podcast on fluids for resuscitation with Rory Spiegel/
Let's get right to it...it’s time for Last Week Now!
You may have heard of some people poo-poo'ing bicarbonate pushes on FOAMed....but do you know why? This video is a breakdown of the reasons why I avoid bicarbonate pushes in most situations where other clinicians choose to use it. Long story short, it doesn't work the way most people thinks it does. Want to hear more? Click here for the video.
Video Laryngoscopy Ls. Direct Laryngoscopy? Which has better first pass success?
In the most recent issue of NEJM, Dr. Steve Schauer (@armyemdoc) and colleagues published a large RCT trial looking at first pass success with video vs. direct laryngoscopy. This trial demonstrated that DL was inferior to VL. It was so inferior that the trial was stopped early. This is the largest trial of its kind to date, and it is not without controversy. Proponents of DL state that direct laryngoscopy is a skill that trainees should master and a trial like this threatens that teaching. Other state that this cannot be extrapolated to anesthesiologist or anyone outside of EM and CCM. We'll be reviewing this article this upcoming week, but I encourage you to check out the threads on twitter debating these results. Here's the article to read for yourself.
Dr. Tarlan Hedayati delves into the world of chest tubes, focusing on their use in pneumothorax and hemothorax cases. While chest tubes are commonly used, they come with potential complications. We discuss some horrifying cases to highlight the importance of proper placement. However, complications occur in about 30% of chest tubes, making it crucial to determine which cases require intervention and which can be safely observed. She presents a study that challenges the traditional teaching of intervention based on pneumothorax size. According to the study, even large pneumothoraces (greater than 32%) can be observed without intervention, as long as the patient is hemodynamically stable and closely monitored. Tarlan provides insight into the study's methodology and outcomes, suggesting that the 10-20% pneumothorax observation threshold may no longer be valid. She reviews the guidelines so hemodynamically stable patients can avoid unnecessary chest tube placement, reducing complications, hospital stays, and the need for rehab. We emphasize the importance of communication with trauma surgeons and provide insights for healthcare professionals working in facilities without trauma centers. Join Tarlan as she navigates the evolving field of chest tube management, promoting patient safety and improved outcomes through evidence-based practices. Remember to like and subscribe for more critical care and emergency medicine content. Hashtags: #ChestTubes #Pneumothorax #Hemothorax #Complications #CriticalCare #EmergencyMedicine #ObservationVsIntervention #NonInferiorityTrial #LargePneumothorax #TensionPneumothorax #35MillimeterRule #BluntTrauma #TraumaticPneumothorax #300MilliliterRule #PredictorsOfFailure
Watch the video here for the entire video from Tarlan.
In this episode, Dr. Rory Spiegel delves into the contentious subject of the benefits and drawbacks of using normal saline during resuscitation. We take a retrospective look at a number of studies and trials conducted on this subject over the years. The early trials pointed to an association between chloride-rich fluids like normal saline and increased renal failure and mortality, but these were often not randomized and potentially biased.
One of the major studies discussed was the Split trial, a randomized controlled trial that found no significant difference in renal failure, need for dialysis or mortality rates between patients given normal saline or plasmalyte. Another critical study, the SMART trial, caused much anticipation as it aimed to identify the harms of normal saline. However, this trial too showed no significant difference in Acute Kidney Injury (AKI), need for renal replacement cells or mortality.
A controversial aspect of the SMART trial was the use of a composite outcome called Make 30, a measure combining an increase in creatinine, need for dialysis and an increase in mortality. It was observed that there was a 1.1% absolute increase in the rate of Make 30 events in patients who received normal saline. However, questions have been raised about the reliability of such composite outcomes and their ability to mask random chance.
Finally, we discussed the BASICS trial, a randomized trial that compared balanced solutions and normal saline in critically ill patients. The findings paralleled the SMART trial, showing no significant difference in survival rates, renal failure, or need for dialysis.
In conclusion, despite early studies indicating potential harm from normal saline during resuscitation, large, well-executed studies like the BASICS and SMART trials have shown that the risk associated with normal saline is virtually non-existent. The discussion should now shift away from the type of fluid being administered to how much fluid and how it's being given. These factors are likely to have more significant implications on patient outcomes.
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