Bret P. Nelson, MD, RDMS, FACEP Courtesy of Bret Nelson Twitter: @bretpnelson Website: SinaiEM.us YouTube: SinaiEMultrasound Bret Nelson is a Professor of Emergency Medicine, Chief of the Emergency Medicine Ultrasound Division at the Icahn School of Medicine at Mount Sinai, Chief Editor of the ultrasound education website, www.SinaiEM.us. He is on the board of directors of the Society for Clinical Ultrasound Fellowships and active in the American College of Emergency Physicians (ACEP)'s Ultrasound Section and is among the authors of ACEP's Emergency Ultrasound Guidelines. Served on the Board of Directors of the World Interactive Network Focused on Critical Ultrasound (WINFOCUS) and was Chair of the American Institute of Ultrasound in Medicine’s Point of Care Community of Practice Authored several books, Manual of Emergency and Critical Care Ultrasound, Emergency Medicine Oral Board Review Illustrated, Atlas of Handheld Ultrasound, and Acute Care Casebook. Dr. Nelson has lectured throughout the world on the use of point-of-care ultrasound to aid medical decision-making and improve patient safety. His research interests include ultrasound and medical education. Want to take a Ultrasound Guided Peripheral IV Intensive Course? We have one coming up! Saturday October 13, 2018 We're providing a 4:1 attendee to instructor ratio in a 4 hour training program so you get tons of hands on experience to learn this awesome skill! Spots are limited! Sign up and complete info here at EventBrite  Resus Nurse Podcast and Blog Discount: ResusNurse10 USG PIV Course10132018 PDF Missed 021 Nurses Placing Ultrasound Guided IV Access w/Bret Nelson, MD Episode? Click Here "This isn't some brand new skill. This is a technique through which you can optimize your existing skills in venous access." ~Bret Nelson How to Start a Nurse Ultrasound IV Training Program?! Nurse Driven Program Nurses interested in ultrasound should be the course director(s). Doesn't necessarily have to be the unit Nurse Educator. If working with MD, have multiple Course Directors or MD can be there to help out initially. Nurses can and should drive this program. Nurses teaching nurses a new skill offers insight that providers aren't able to provide. Only takes 1-2 Nurses to drive practice change within a unit! Multidisciplinary Course Directors and/or Instructors (RN and MD) Both nurses and physicians bring a lot of their own skills to the table. Combining skills, we learn from each other and ultimately become better at obtaining IV access with ultrasound use. ED Initiative for ED Nurses and ED Culture Utilizing Multidisciplinary Support A positive initiative that improves patient care. We created a culture where once a nurse finishes competency, they are able to place ultrasound-guided IV access on their own. Sometimes, you run into trouble and usually it's because the patient has limited veins, so they are still able to ask for help. Have another person look with the ultrasound. It's okay to ask for help! This has also increased more collegial respect between disciplines and increased teamwork. Nurse buy-in and Physician buy-in We decided to make this program optional for nurses. Currently we only have this program for our adult population in the ED. Nurses love the program and so do our patients! Support from Nursing and Physician Leadership Talk to your Nursing and Physician Directors of your department. Keep them in the loop. I have found Leadership to be extremely supportive and helpful. Nursing Policy and Nursing Education Written policy for nurses is important to have in writing within your department/institution. Work with your Nursing Director and/or Nursing Education in order to develop policy if it's not already written or change/expand existing policy. Know your policy. Some may restrict this skill to nurses working in specific departments.

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022 How to Start a Nurse Ultrasound IV Access Training Program w/Bret Nelson, MD

Bret P. Nelson, MD, RDMS, FACEP Courtesy of Bret Nelson Twitter: @bretpnelson Website: SinaiEM.us YouTube: SinaiEMultrasound Bret Nelson is a Professor of Emergency Medicine, Chief of the Emergency Medicine Ultrasound Division at the Icahn School of Medicine at Mount Sinai, Chief Editor of the ultrasound education website, www.SinaiEM.us. He is on the board of directors of the Society for Clinical Ultrasound Fellowships and active in the American College of Emergency Physicians (ACEP)'s Ultrasound Section and is among the authors of ACEP's Emergency Ultrasound Guidelines. Served on the Board of Directors of the World Interactive Network Focused on Critical Ultrasound (WINFOCUS) and was Chair of the American Institute of Ultrasound in Medicine’s Point of Care Community of Practice. Authored several books, Manual of Emergency and Critical Care Ultrasound, Emergency Medicine Oral Board Review Illustrated, Atlas of Handheld Ultrasound, and Acute Care Casebook. Dr Nelson has lectured throughout the world on the use of point-of-care ultrasound to aid medical decision-making and improve patient safety. His research interests include ultrasound and medical education. "10 years ago a patient will say, 'Only Mary on the 9th floor is going to get near my vessels'....now the patients say, 'I'm a tough stick, so use ultrasound.' It's almost like anyone can get a pass from the patient's perspective...ultrasound is the great equalizer." ~Bret Nelson Can RNs perform USG PIV safely? Yes! Within Nursing Scope of Care!! Yes!! American Institute of Ultrasound in Medicine (AIUM) White Paper in conjunction with: American Academy of Physician Assistants (AAPA) American Association of Critical Care Nurses (AACN) American Association of Nurse Anesthetists (AANA) American Society of Diagnostic and Interventional Nephrology (ASDN) American College of Emergency Physicians (ACEP) American Society of Echocardiography (ASE) Association of Physician Assistants in Cardiovascular Surgery (APACS) Association for Vascular Access (AVA) Infusion Nurses Society (INS) Renal Physicians Association (RPA) Society of Diagnostic Medical Sonography (SDMS) Society for Vascular Ultrasound (SVU) Emergency Nurses Association (ENA) Clinical Practice Guideline for Difficult IV Access Why Nurses? Nurses are masters at IV insertions Ultrasound is another tool in the tool belt for difficult IV access. Ultrasound is a natural progression for nurses who are experienced in obtaining IV access Nurses have the best tricks to get those tough IV lines like applying heat. Nurses already use other technology including infrared light, LED, and head lamps Journal articles show high success rate! ~85 after approximately 10-15 attempts ~95% after approximately 20-25 attempts Too many articles - click here for dropbox link and easy download. Empowering nurses with an advanced skill Nurses are able to identify a patient as a hard stick and obtain IV access with ultrasound without waiting for a physician to place the IV. Nurses who need to develop their IV skills have a skill to strive for. Patient Satisfaction Nurses are able to identify patients who are a hard stick. Patients have reduced failed attempts prior to an ultrasound guided placed IV access. Essentially, patients get stuck less but get good results. Patients know they are a hard stick - they are happy. Who Should be getting USG PIV? Patients who have difficult intravenous access. *If you can place an IV in a conventional or traditional method, do it. ~Yun Cee Identified difficult IV access populations: Oncology/Chemotherapy Sickle Cell Renal/Hemodialysis Obese Repeat Hospital Admissions Shock IV Drug Abuse Diabetic Edematous Dehydration Pediatric Reduces CLABSI by NOT placing central venous lines because you have peripheral IV ac...

021 Nurses Placing Ultrasound Guided IV Access w/Bret Nelson, MD

  Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally   Missed Episode 011? Low Dose Ketamine for Pain - Administration Explained! Click Here Missed Episode 018? Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More Click Here A Candid Conversation on having a Hydromorphone-Free ED with Sergey Motov, MD FAAEM This episode was recorded earlier in the year at the same time as the Deep Dive Continuous Sub-Dissociative Dose Ketamine discussion. Are people forgetting how powerful hydromorphone is? Some people do forget, majority have not been educated. Why are we now using so much hydromorphone? This medication was basically thrown at us. "Use it. It’s a great and safe medication alternative to morphine." Without actual explanations of equi-analgesic conversion, potency, or lipophilicity (lipid solubility) in comparison to morphine. Morphine 8mg or Hydromorphone 1mg? There’s something mental about giving a single digit dose of an opiod versus double digit. It’s much easier to prescribe 1mg, 2mg, 3mg…6mg of hydromorphone than let’s say 10mg of morphine without understanding that hydromorphone 2mg = morphine 16mg. Hydromorphone 1mg = Morphine 8mg Hydromorphone 2mg = Morphine 16mg 48% ED attendings lack pharmacological understanding or validity of why they are using one opioid over another Opioid-Naive Patients First-line medication - should NOT be hydromorphone Initial hydromorphone dose should be 0.2-0.4mg (If you must, for opioid-naive patients) Conversion: Morphine 2-4/5mg dose How to administer opioids? Titrate at Specified Intervals *Clinical Pearl Single dose of opioids will not do the trick. No matter how you dose it (weight based or fixed). Start with a lower dose. Reeval every 10-15 minutes. Ask the patient if they need more. Give another dose as needed. Repeat. No need to wait 4 hours for the next opioid dose. Morphine peak time ~20 minutes Hydromorphone peak time ~15 minutes Morphine, hydromorphone and fentanyl are pure mu receptor agonists with no analgesic ceiling. Titrate opioids up until one or two things will happen: Pain is optimized or they stop breathing Clinical Example: Patient received 3 doses of morphine: 4mg, 4mg, 4mg. Still has pain. Now what? You want to give an opioid. Which one? Some may switch to hydromorphone. But why? Hydromorphone is not any different than morphine except for potency. The most potent opioid is fentanyl. Problem is fentanyl has a shorter half life so will have to re-dose more often. Consider adding non-opioid analgesic modalities If you do switch to hydromorphone - remember to add previous morphine doses and convert equianalgesia for total dosage. i.e. Morphine 12 mg (4mg x3) + Hydromorphone 1mg (Morphine 8mg) = Morphine 20mg Opioid-Induced Hyperalgesia The longer a patient uses opioids to treat pain, the patient will most likely develop hyperalgesia and will ultimately require a higher dose to treat their pain which will eventually lead to tolerance and possibly addiction. Constantly requires a higher dose. Hydromorphone has a Higher Abuse Potential than Morphine Hydromorphone is 10x more lipophilic than morphine. Penetrates the blood brain barrier significantly faster and saturates the mu receptors faster. It translates to a euphoria,

020 A Hydromorphone-Free ED? w/Sergey Motov, MD

Nursing Intubation Checklist - Yes, Really. Over the years I’ve developed a personal Nursing Intubation Checklist that I have for myself when preparing for RSI, DSI, or an awake intubation. This has saved my ass while working on very sick patients. Some of my checklist items cross over with the provider’s checklist. I’m sure it will evolve and I will update as needed. You may still be scrambling, but you can save yourself from going into a panic mode if your patient starts crashing and you’re trying to do everything so you don’t need to start compressions - tall order. Generally, I don’t hand over the intubation meds to the doctors until MY checklist is complete. There’s almost always time with DSI and awake intubations. With RSI you may not have as much time and you may need to hand over the intubation meds before finishing your checklist - the patient needs the airway NOW. Do you have a Nursing Intubation Checklist? Looking forward to having feedback and a discussion as to what should be added or taken away. Intubation has 4 main Parts The Decision to Intubate Setting Up for Intubation Intubation Post Intubation Care Some of my thoughts on Intubation Communicate with your provider as to what the plan of care is: BP low - do we need push dose pressors or vasopressors before and/or after intubation? Are we anticipating central line or A-line? Post Intubation Care is the most critical part of intubation (in my opinion) and it's VERY NURSING HEAVY. Providers should stick around and watch the patient. Patients like to crash right around this time. If your provider is not your ED Provider, they really need to stick around and not go upstairs. The more you have set up PRIOR to intubation, the SMOOTHER your post intubation care. Soooo Nursing Heavy that there will be a separate episode on Post Intubation Care...stay tuned! Here’s my Nursing Intubation Checklist 2-3 IV lines I prefer 3. Sometimes I even put in 4 or 5. Just depends on what I need or anticipate. Especially if they are very sick and you have a sneaky suspicion that you will need a NE drip for a crashing BP. You may need PDP but if you already have a drip ready to go - even better! Mentally think which medications and how many lines you need. Not all medications are compatible through the same line. Pet Peeve Alert! If a provider tells you, don’t worry about the extra IV line, we’ll put in a central line afterwards - don’t listen to them! If your patient is sick enough that the provider is already anticipating the need for a central and/or A line - you betcha you will need those extra IV lines while it takes them 20-30 minutes to put in that central line. Your patient may not have 20-30 minutes to spare if they are that sick because remember, you are doing a lot of medication adjustments for post intubation care. Make sure these are actually good lines. If they are not, this is the time to put in an ultrasound guided peripheral IV line or two. Traumatic Arrests or Hemorrhagic Shock may require 18 gauge or larger IV lines for massive blood transfusion. Pet Peeve Alert! But my rule of thumb is, if you can DEFINITELY get a 20 gauge in - I’d rather that you get the IV line rather than trying to only go for an 18 gauge or larger and then blowing all of your lines. This is not the time to have your ego in the way of patient care. The larger IV lines, if still required, can be placed after intubation with ultrasound guided peripheral IV placement in this situation. Your provider should also be thinking about inserting a cortis so you can rapidly infuse blood products through that line. If you're the provider - communicate this thought process to your nurse. Verbal Orders of Intubation Medications AND Post-intubation sedation. Both set of orders PRIOR to intubation - you will have a smoother transition for your patient during...

019 Nursing Intubation Checklist

Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally Missed the Low Dose Ketamine for Pain - Administration Explained! Episode? Click Here We wanted to do a Follow-Up Episode about Sub-Dissociative or Low-Dose Ketamine (SDK) Infusions. Then this research got published... Continuous Intravenous Sub-Dissociative Dose Ketamine Infusion for Managing Pain in the Emergency Department Authors: Motov, Sergey; Drapkin, Jefferson; Likourezos, Antonios; Beals, Tyler; Monfort, Ralph; Fromm, Christian; Marshall, John Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health Publication Date: March 3, 2018 Sergey is back and talks about his research and findings... Impressive Pain Reduction >3 on Numeric Pain Scale 60 Minutes, 65% of Patients 120 Minutes, 68% of Patients How does Continuous SDK Infusion Work? "Ketamine's rapid onset, and super rapid saturation of N-methyl-D-aspartate (NMDA) receptors and will give you an initial jolt of pain relief. But if you do it relatively slowly, the saturation will be a little slower, but it will last much, much longer. That's why I believe the results of patients experiencing significant reduction of pain at 60 and 120 minutes, a direct consequence of this particular way of giving ketamine." - Sergey Motov, MD Most Patients Enrolled in Study Received a Loading/Short Bolus Infusion prior to Continuous SDK Infusion Who received the most benefits? Patients with... Oncology/Cancer Pain (Chronic and Metastatic) Oncology patients normally have multiple modalities to treat their pain. Can have very high baseline PO opioid doses (i.e. morphine 300mg PO, fentanyl patches). Administering morphine 4mg or hydromorphone 1mg IVP will do absolutely nothing for these patients. The opioid dose needed is so high that the side effects are intolerable (i.e. nausea, vomiting). Increase CNS depression, respiratory depression, morbidity, and mortality in very high, inhumane doses. Continuous Sub-Dissociative Ketamine Infusions can be used as an adjunct therapy FYI: Ketamine comes in PO form (pill and liquid) Ethical Alert! Concern for abuse is real, don't prescribe it. Highly addictive and highly abused. Just know that it's out there, may have application to some chronic oncology patient population. Abdominal Pain (Pancreatitis, Intractable, Unknown Etiology) Sub-Dissociative Ketamine is the most beneficial modality for chronic intractable pain with or without non opioid adjunct therapy with functional abdominal pain (i.e. secondary to toxicology emergency). Psyche component for unknown etiology abdominal pain? Simple conversation with biofeedback, psycho-social counseling, encouragement, and reassurance Normal Physical Exam May not need any interventions Sickle Cell Crisis Pain Use of continuous SDK infusion decreases opioid needs by 50% Barriers: Admitted Sickle Cell Crisis Patients will not get SDK infusions on inpatient units and will go back to hydromorphone PCA pumps Inpatient Providers' and Nurses' familiarity and understanding of SDK infusions Convincing Patients to try SDK as adjunct therapy for pain Interdepartmental protocol. Work Around: Admit patients to an observation unit with SDK protocols in place. Utilize Clinical Nurse Educators to develop nursing policy. Interdisciplinary SDK protocol can be developed with ED Medical Director, ED Nursing Director, and Pharmacy.

018 Deep Dive on Continuous Sub-Dissociative Dose Ketamine Infusions, Ketamine in Geriatrics?, Ethics & More w/Sergey Motov, MD!

Who is Arlene Chung, MD? Courtesy of Arlene S. Chung, MD, MACM Arlene S. Chung, MD, MACM  Arlene is an Associate Residency Director for the Mount Sinai Emergency Medicine Residency Program in New York City. She has a passion for physician wellness and has made advocating for well-being a central focus of her career. She holds leadership roles in multiple regional and national wellness organizations and has lectured extensively on physician wellness, developed mindfulness curricula for students and residents, and published on the current issues surrounding wellness and burnout and possible solutions for the future. Twitter @ArleneSujin What is Airway: True Stories from the Emergency Room? Arlene is also one of the co-founders of a non-profit organization known as Airway: True Stories from the Emergency Room. Airway originally began in 2015 as a series of free New York City-based storytelling events for EM physicians with the mission of creating community, decreasing stigma, and fostering resilience through the vulnerability and shared experiences of storytelling. Airway events have since been organized in cities across the country and at multiple regional and national conferences including the AAEM Scientific Assembly, FemInEM Idea Exchange (FIX), and the NY ACEP Scientific Assembly. AIRWAY LIVE NYC EVENT AIRWAY and RESUS NURSE Podcast Listener CONTEST!! Arlene and I want to hear YOUR stories! Send us a pitch at info@resusnurse.com with your name and email address! We'll select our favorites and air them at a later episode! Deadline: May 31, 2018 Now Listen to the Episode...Be Prepared to Laugh and Cry... Cite this post as: Yun Cee Dirsa. 017 AIRWAY True Stories from the Emergency Room w/Arlene Chung, MD. Resus Nurse Podcast and Blog. Published on March 25, 2018. Date accessed January 19, 2020. Available at https://resusnurse.com/2018/03/25/airway-true-stories-from-the-emergency-room-w-arlene-chung-md/.

017 AIRWAY True Stories from the Emergency Room w/Arlene Chung, MD

"This used to be merely intuition...even a minute or two at low MAPs may be too much and certainly waiting 20 minutes for pharmacy to send up a drip is probably way too long...and your kidneys may actually be getting damaged in that short period of time." - Scott Weingart, MD Who is Scott Weingart, MD? Courtesy of Scott Weingart, MD Scott D. Weingart, MD FCCM FUCEM DipHTFU Scott is an ED Intensivist from New York. He did fellowships in Trauma, Surgical Critical Care, and ECMO. He is currently an attending in and chief of the Division of Emergency Critical Care at Stony Brook Hospital. He is a clinical associate professor of emergency medicine at Stony Brook Medicine and an adjunct associate professor at the Icahn School of Medicine at Mount Sinai. He is best known for talking to himself about Resuscitation and Critical Care on a podcast called EMCrit, which has been downloaded > 19 million times. EMCrit Twitter Team @emcrit What is a MAP? (Mean Arterial Pressure) Average pressure in a patient’s arteries during one cardiac cycle Really good number to measure organ perfusion Systolic BP is a useless measurement in super hypotensive patients Calculations: MAP = CO x SVR MAP = SBP + 2(DBP)/3 Low MAPs should be treated as an Emergency = Requires Good Nursing!! What is a minimal MAP for adequate perfusion? No one knows!!  Minimal MAPs (what we think and have made up) to adequately perfuse 3 main organs. Use this as a loose guideline. May have to individualize for each patient.   Brain MAP 60-65 but can go lower for a bit of time before damage MAP 40 starts to have altered mental status Heart MAP 60-65 Kidney MAP 65 super sensitive to low MAPs May not be able to measure output in ED if kidneys were hit hard and due to shunting In the ED, we like MAP 65... because the organs will have minimal perfusion and we often don't know what the medical history is or have had 24 hours of patient observation.  Normal MAP + Low SBP + Normal DBP = Okay Organs are being perfused Low MAP + Normal SBP + Low DBP (Ex: 100/20) = Badness Can be in cardiac arrest if you don't pay attention and do something ASAP Low MAP, How long is too long? New Anesthesia literature that shows a minute or two may be too much. Concern for kidney injury Hearts may dislike low MAP esp. Pts with cardiac history. React quickly to low MAPs (MAP 40s and 50s) No barrier to treating low MAPs No Harm in treating low MAPs Can start peripheral NE drip and if in 45 minutes, NE drip is titrated off - no harm done to Pt Wait and See approach with fluids doesn't work Fluids don't last to maintain MAPs, it will drop 30-60 minutes later Harm to keep Pt at low MAPs "Permissive Hypotension" A confusing term No one is really in a permissive hypotension state lower than the minimal MAP 65 Trauma A confusing term because the trauma studies still show that a Pt is being perfused and hovering around MAP 60-65 Term came about because fluids were restricted instead of giving bunch of fluids - but BPs were normal Some say the clot is formed so don't break the clot - still BPs are at MAPs that we talked about Bickell study on penetrating trauma Scott mentioned Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma by D. Kudo Rick Dutton Approach for penetrating trauma management as described by Scott Keep your patient from being vasoconstricted Organs are not being perfused with higher MAP but in fact exsanguinating due to vasoconstriction Manage by hovering around a MAP 60-65 and perfuse organs MAP 80 (or whatever upper limit you decide), give them some anesthetic and dilate them. Fentanyl is an indirect vasodilator Read more about Richard Dutton and trauma at emcrit.org Hemostatic Resuscitation Hemorrhagic Shock Patient in Trauma Neuro - term doesn't really apply

015 How Low Can You Go? Hypotension is an Emergency w/Scott Weingart, MD

"I find it very gratifying to treat because you can see the effects of your treatment right in front of your eyes. And your patients can go from very sick to well within a matter of hours." - Marc Probst, MD Who is Marc Probst, MD? Courtesy of Marc Probst, MD Marc Probst, MD, MS is an Academic Emergency Physician at The Mount Sinai Hospital in New York City. Dr. Probst is funded by a career development grant from the National Institutes of Health (NIH). His interests include syncope, shared decision-making, and Halloween. Twitter @probstMD   Diabetic Ketoacidosis (DKA) Biochemical Findings Hyperglycemia Ketosis (High anion gap) Metabolic Acidosis Parameters to treat DKA Blood glucose >250mg/dL Elevated anion gap w/albumin adjustment >10 Serum bicarbonate 

014 You’re TOO Sweet! DKA Emergency w/Marc Probst, MD

Markus dela Cruz, RN Mark is an ED Nurse extraordinaire who turned into a Cath Lab RN. He is also found working in PACU units and still works some ED shifts. Mark also considers himself a foodie and likes exploring Queens, NY. Mark works at a Level 1 Trauma Center that is also a STEMI receiving center in Queens, NY. Fun fact: When I first started working, there were rumors that Mark can get an IV line with a full set of labs on sick patients with NO tourniquet! To this day, I believe this may be more truth than fiction. Disclaimer: This is how Mark and I manage our STEMI patients going to the Cardiac Cath lab for PCI. These are suggestions. Follow your institution’s policies. "The minute that fellow or that doctor opens up that vessel - you see the color returning, pt's vital signs are stabilizing, and the pain is completely gone. I'm having goosebumps telling you this. " - Markus dela Cruz, RN Need to listen to Part 1? Listen to Part 1 of my discussion with Markus dela Cruz, RN where we went over all the nitty gritty details on how to send your STEMI patient to the Cath lab STAT! PCI Post Cardiac Arrest Who is eligible? Patient Viability How long patient was down for? Safe for patient? PCI will be adding more stress to the heart Involve Family for shared decision making Considerations Send your patient ASAP! Send your patient with a secured airway Cath Lab MDs are unable to assist with a code or intubation - they are scrubbed in. May only have 2 nurses running the code. Pt most likely in cardiogenic shock If Pt codes during transfer and/or at the Cath lab - Door to balloon time of 

013 Part 2 – PCI Post Cardiac Arrest w/Markus dela Cruz, RN

Markus dela Cruz, RN Mark is an ED Nurse extraordinaire who turned into a Cath Lab RN. He is also found working in PACU units and still works some ED shifts. Mark also considers himself a foodie and likes exploring Queens, NY. Mark works at a Level 1 Trauma Center that is also a STEMI receiving center in Queens, NY. Fun fact: When I first started working, there were rumors that Mark can get an IV line with a full set of labs on sick patients with NO tourniquet! To this day, I believe this may be more truth than fiction. Disclaimer: This is how Mark and I manage our STEMI patients going to the Cardiac Cath lab for PCI. These are suggestions. Follow your institution's policies. Your Patient's Going to the Cath Lab! How can we ensure the fastest and smoothest transition from the moment your patient is identified as a STEMI and accepted to the Cardiac Cath lab? PCI (Percutaneous Coronary Intervention) is the treatment of choice for a repercussion of a patient having an active MI. It is a life-saving procedure. You may be a receiving facility getting transfers. If your facility does not have a Cath lab, you will transfer to a facility that does. 3 Sites of Entry: Right Radial Artery and Bilaterally Femoral This is a CMS reportable event and the door to balloon time is within 90 minutes. Preferably, you get your patient into the Cath lab WELL before the 90 minute mark because your Cath lab team have a lot to do. Prepping Your Patient Get your patient butt naked! Seriously, no underwear! (A running theme!) IV Medlocks Minimum 2 IV medlocks. 3 is super! Avoid Right Wrist and Right Hand. Left arm preferred Vitals also include: Weight All medications given in the Cath lab are weight-based. Height intra-aortic balloon pump is sized by height EKGs (just leave the leads on! You'll be repeating these!) Defibrillator Monitoring (use radiolucent pads) Telemonitoring & transport monitoring (esp. your cardiogenic shock pts) Not all facilities have fancy defibrillator monitors that also have BP and Pulse Ox. If you do, obviously use it! History Ask the patient and/or EMS what meds were given (esp. aspirin dose) Consent Can we trust the Cath fellow with the original? If we have time, I usually make copies and tape it to the top of the stretcher and get it scanned in the ED Chart. Secure all property and jewelry with family member or security - label and seal the property bags. Keep left chest wall and right wrist clear of all jewelry. Document in chart where property went. Medications All Patients with STEMI Aspirin 325mg PO If EMS gave 2 baby aspirins (81mg each), give another 2 for a full dose of 325mg Heparin Bolus IV Most facilities are weight-based, but some still give the standard 5000 units IV Heparin IV Myth-Buster! Always administer bolus dose heparin by IV. Never subcutaneous! IV Heparin helps prevent the existing clot to not get larger and prevents new clots aPTT in anticoagulated therapeutic range is the goal! Don't wait for an aPTT/INR result before administering Heparin IV. Pts need to be anticoagulated because PCI attracts clot formation. Cath labs have fancy machines that measure aPTT and INR in real time and can adjust heparin as needed. ACT (Activated Clotting Time) Machine Worse case, heparin's antidote (protamine sulfate) is readily available in the Cath lab. If PCI w/Stents Loading doses of clopidogrel (Plavix) and ticagrelor (Brilinta) Additional Medications Heparin Drip When did you start it? What's the current dosage/rate? If the pt received thrombolytics and you are a receiving hospital, pt should most likely be on a heparin drip to prevent further clots. Speak with Cath fellow/cardiology/EM MD. NSTEMI patients boarding in your ED may be on a heparin drip. Check aPTT every 6 hours and adjust drip as needed for anticoagulated therapeutic levels - goal...

012 Your Patient Is Going to the Cath Lab!!! Part 1 w/Markus Dela Cruz, RN

Sergey M. Motov, MD, FAAEM Courtesy of Sergey M. Motov, MD Twitter @painfreeED Dr. Motov is an Emergency Medicine Physician practicing in the Department of Emergency Medicine at Maimonides Medical Center, Brooklyn, New York. He graduated from Medical Academy of Latvia and completed his EM residency at Maimonides Medical Center. Dr. Motov is an Associate Research Director who is passionate about safe and effective pain management in the ED.  He has numerous publications on the subject of opioid alternatives in pain management, and is actively involved in growing this body of work both nationally and globally.  "In the 7 years I've been administering ketamine for this application, I've never had a patient walk into my ER and ask, 'Can I get ketamine?'" - Sergey Motov, MD     Who gets low-dose ketamine for analgesia? Patients who fail initial 3+ opioid doses. Patients generally with chronic pain, neuropathic pain, oncology pain, opioid tolerance, polytrauma. Great medication for treating pain and doesn't have the same addictive qualities as opioids. Ketamine is abused, namely in China. In the United States, we don't see it as much. Low-Dose Ketamine Bolus Dose for Analgesia 0.3mg/kg in NS 100mL infused over 15 minutes (400mL/hr) Max dose 30mg **Reduces the feeling of unreality in comparison to administering IV push. Basically, your patient won't freak out! (at least much less episodes!)   Bolus Administration Pearls: No pumps are needed for the bolus dose administered as a short infusion. But doesn't hurt either. No monitors needed. Low-Dose Ketamine Drip Dose for Analgesia 0.1mg/kg as a continuous infusion Titrate every 30 minutes as needed - involve provider when titrating. 0.1-0.3mg/kg 0.4-0.7mg/kg --> you've now entered a recreational dose Preparation: Ketamine 100mg in NS 100mL = 1:1 ratio Infusion Pearls: Must use an iv pump to administer the infusion. Use nursing judgement for telemonitoring. Majority of patients will get discharged after 2-3 hours of continuous therapy. Look at the presentation of the patient. Not everyone will need an infusion. Many patients will find relief with the bolus dose alone. Some may need both the bolus and infusion. Dose obese patients with an ideal body weight. Logistics: Ketamine comes in 2 different concentrations: 10mg/mL and 50mg/mL Much easier to calculate and draw up ketamine with the 10mg/mL concentration with this application! Worried about waste? Pharmacy can keep a single dose vial with 10mg/mL concentration for 24 hours and use it as a multi-dose vial. They will have to prepare all of your ketamine bolus infusions and ketamine continuous infusions - wouldn't that be nice? Now Listen to the Episode... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 66(3). doi:10.1016/j.annemergmed.2015.03.004 https://www.ncbi.nlm.nih.gov/pubmed/25817884 Lee, E. N., & Lee, J. H. (2016, October 27). The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis.  https://www.ncbi.nlm.nih.gov/pubmed/27788221 Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – 7.  PMID: 28283340 Ketamine: How to Use it Fearlessly For All its Indications by Reuben Strayer. (2015, December 06).

011 Low-dose ketamine for pain administration explained! w/Sergey M. Motov, MD

Who is Reuben Strayer, MD? Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure A Special K Trip Part 3 - Ketamine for Analgesia & Tranquilization And now for the conclusion of the 3-part ketamine series with Reuben Strayer. Today’s episode is Part 3 focusing on Ketamine for analgesia and extremely uncontrollable violent patients. If you haven’t already, go back and listen to Episode 7 where Reuben talks about ketamine and how different dosing can have different applications in the ED setting. In Episode 8, Reuben talks about ketamine for PSA & RSI. Ready to continue with your Ketamine trip w/Reuben? Here we go! Ketamine for Analgesia Who gets ketamine? Chronic pain, poly trauma, oncology pain, etc. Dosing 0.3mg/kg 0.1-0.3mg/kg have been used. No pumps for bolus dose? No problem. Of course, administering through a pump will always be the gold standard. How to administer: Inject the analgesic dose into NS 100mL and infuse over 15 minutes. 15 minutes = 400mL/hr (best!) 10 minutes = 600mL/hr (not much difference) Why are we diluting the ketamine dose for administration? To prevent psychiatric emergence or your patient from "freaking out." Ketamine drips - always use a pump. (Not everyone will get a drip) 0.1mg/kg and titrated every 30 minutes. No monitoring required. *Use your discretion, if you feel that your pt needs monitoring - put your patient on a monitor and alert your provider. Some pretty good articles, full list below: Sergey Motov's article on ketamine for pain in the ED Cheryl Allen's article on administering ketamine in Pain Management Journal Sergey Motov interviewed on ketamine in EP Monthly Ketamine for Tranquilization Who gets it? Your huge guy where you have a small army of security and staff trying to hold him down and you are concerned for the patient's and staff's safety. How often are you using this? Rarely. Dose Dissociative Intramuscular (IM) Dose: 4-6mg/kg 500mg IM Adult dosing = approx. 100kg person Monitoring required with airway capable provider at bedside.  Safety Pearl for Violent and Agitated patients (whether you use ketamine or not): Don't attempt to put in an IV line! (If your provider asks, say "No thank you!") Administer IM through the clothing. No alcohol swab needed. Team approach to hold down patient for patient and staff safety. Now Listen to the Episode... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine, 66(3). doi:10.1016/j.annemergmed.2015.03.004 https://www.ncbi.nlm.nih.gov/pubmed/25817884 Lee, E. N., & Lee, J. H. (2016, October 27). The Effects of Low-Dose Ketamine on Acute Pain in an Emergency Setting: A Systematic Review and Meta-Analysis.  https://www.ncbi.nlm.nih.gov/pubmed/27788221 Motov S et al. A Prospective Randomized, Double-Dummy Trial Comparing Intravenous Push Dose of Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment of Moderate to Severe Pain in the Emergency Department. AJEM 2017; S0735 – 6757(17): 30171 – 7.  PMID: 28283340 Ketamine: How to Use it Fearlessly For All its Indications by Reuben Strayer. (2015, December 06). https://www.smacc.net.au/2015/12/ketamine-how-to-use-it-fearlessly-for-all-its-indications-by-reuben-strayer/ Strayer, R. (n.d.).

010 A Special K Trip Part 3 (Analgesia & Tranquilization) w/Reuben Strayer, MD

Reuben Strayer, MD Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure     Ready to continue your Special K Trip? Today's episode is Part 2 out of a 3-part series and will cover the use of ketamine for procedural sedation and intubations in the ED with Reuben Strayer, MD. If you didn't listen to Reuben talk about ketamine, the safety measures of ketamine, or confused by this graphic with different dosing - go back and listen to Episode 7 for Part 1 where this is explained in detail.   Ketamine for Procedural Sedation and Analgesia (PSA) Prep Your Patient Therapeutic Communication - let your patient have whatever fantasy they want and encourage it! Any fantasy can be a reality with ketamine...seriously. If they are in so much pain that they are already freaking out and you're not doing your procedure you can give opioids to help calm them down - but remember, ketamine is a powerful analgesia as well...you can always keep them dissociative for a longer duration of time. Situation dependent. Administer your ketamine dosage diluted in Normal Saline and give it slow...best method to prevent psychiatric disturbance. Prep Yourself Place patient on continuous telemonitoring and pulse oximetry Bonus points: CO2 monitoring Airway capable Doctor Watch respirations and breathing closely May have periods of apnea Prevent apnea by administering ketamine slowly (approx. 2 minutes diluted or diluted in Normal Saline 50/100mL over a longer period of time) Expect apnea if you administer ketamine as a fast IV push bolus (1-2 seconds) Patient may still have apnea - MD must know maneuvers to open airway (head position, jaw thrust, BVM, intubation) Nasal Cannula on patient - turn on oxygen as needed I like to have everything connected even if the oxygen is turned off NRM on standby Airway Cart, BVM, and Intubation Kit on standby Suction on standby Nurse who is dedicated to monitor sedation - lots of paperwork and frequent monitoring including watching those respirations! Consent PSA Ketamine Dose Reuben gives a dissociative dose (Ketamine 1-1.5mg/kg). You can get away with giving an analgesic dose but if a patient comes in with a bad fracture - give the dissociative dose and have propofol on hand to counter ketamine's side effects. Ketamine can be used as monotherapy for PSA. Propofol - to counter ketamine's effects (HTN, muscle rigidity, psychiatric emergence, etc.) Draw up in separate syringe. Administer in 20/30/40mg IV pushes as needed Ketofol - Effective but you are not dosing propofol separately. What is it? Ketamine and propofol drawn up in single syringe and administered at the same time. Always Treat Psychiatric Disturbance As your patient metabolizes the ketamine, your patient may "freak out" or have a psychiatric emergence and you must always treat it. It's inhumane to not ignore it and let the patient "ride it out." Use conventional medications to treat: propofol, midazolam, haloperidol, droperidol (if you can get your hands on it) Post PSA Ketamine Pearls NPO until fully alert. Don't stimulate patient prematurely. Minimal noise and minimal physical contact. Nurse with patient entire time monitoring patient until fully alert. Ketamine for Rapid Sequence Intubation (RSI) Okay to use for polytrauma or head trauma (ICP) patients. Has neuroprotective properties - good for ICP/head trauma patients. Induction agent independent from paralytic - doesn't matter if you use rocuronium or succinylcholine - but we are fans of rocuronium for RSIs in the ED. Roc Rocks vs. Sux Sucks -LITFL Extra Ketamine in your syringe? Can use like a push dose pressor while setting up post intubation drips.

009 A Special K Trip w/Reuben Strayer, MD – Part 2 PSA & RSI

Courtesy of Reuben Strayer, MD Reuben Strayer, MD Courtesy of Reuben Strayer, MD Emergency Medicine Physician who works in New York City Author of emupdates.com One of the authors of painandspa.org Twitter @emupdates Created the phrase "ketamine brain continuum" No financial disclosure       Back in 2015, Reuben gave an amazing talk on the subject of ketamine and its uses in Emergency Medicine at the SMACC Chicago conference.  It has a lot of fun slides too! I recommend listening to Reuben's SMACC talk first, and then listen to this podcast episode and refer to the show notes. This talk got pretty in depth and long so I broke it up into 3 separate episodes. Today's episode is Part 1, an Introduction to Ketamine.  Part 2 and 3 will cover the applications of Ketamine in the ED in detail. Ketamine Ketamine is traditionally used as an anesthetic in the operating rooms. However, in many ED units, it's commonly used as a procedural sedation agent and an induction agent for intubation. We will be talking about off-label uses including low dose ketamine for analgesia. Take note, you should know your institution's policies. If you don't have one, maybe you can develop some! Safety Alert Must know how to monitor patients who receive ketamine for periods of apnea, psychomimetic disturbances, hypertension, tachycardia. Must have an airway capable provider at the bedside who can quickly intubate if necessary Weight based dosing on all patients. Keep 1 concentration of Ketamine in your ED 2 different concentrations: 100mg/mL and 50mg/mL I like the 50mg/mL concentration and prefer the single-use vials It's easier to push ketamine slower with the weaker concentration.  Otherwise, you can dilute the ketamine. Drawing up ketamine is easier when you want smaller analgesic doses. Also used as a recreational drug (street drug) a.k.a. Special K (not the breakfast cereal), Kit Kat, K, Vitamin C, Cat Valium Major Unwanted Side Effect - Psychomimetic Disturbances or Psychiatric Distress or "K-Hole" (slang) or in other words, they "freak out!" "K-hole" Wikipedia definition: a slang term for the subjective state of dissociation from the body commonly experienced after sufficiently high doses of the dissociative anesthetic ketamine. "K-hole" Urban Dictionary definition (my personal preference): To have used too much of the drug ketamine (special K) and lost sense of time and space, balance, verbal skills. My definition: They are high or stoned out of their mind. Patients can have a good high or a bad high. You'll know the difference right away. You have the power to create a good or bad high. How to mitigate unwanted psychomimetic disturbances? Therapeutic Communication Administer the medication extremely slowly. More evidence is showing that the best way is to dilute your dose into a NS 50mL saline bag (please label it!) and hang it so it's infused in 15 minutes. If you do a traditional bolus push, 3-5 minutes is needed to mitigate psychomimetic disturbances. Give more ketamine to get your patient dissociated. Give propofol to counter ketamine's effects. Give midazalam as another option. Overdosing on ketamine Just prolongs the duration of dissociated state in patient. Look at the Ketamine Brain Continuum slide, the ketamine dosing curve plateaus after the dissociated dose has been reached. Remember, ketamine is weight-based dosing, dosages shown in the slide are for your average adult size. Now listen to the show... References Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283-290. doi:10.4103/0259-1162.143110. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4258981/ Motov, S., Rockoff, B., Cohen, V., Pushkar, I., Likourezos, A., Mckay, C., . . . Fromm, C. (2015). Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial.

008 A Special K Trip Part 1 w/Reuben Strayer, MD

  I’m not a powerful Jedi Master with Force Visions and frankly, unable to see into the future. Hello Star Wars fans!   This is a follow-up bonus episode in response to Episode 5 Push Dose Pressors, listeners' questions, and also in light of recent journal articles that recently got published. Timing was completely coincidental when Episode 5 Push Dose Pressor podcast episode was released.   Although I’ve been using push dose pressors for years now, I still researched the topic awhile ago. Frankly, there wasn’t much out there - and there still isn’t. Why? Because it’s not standard of care. But I suspect it will be once there are RCTs and more research and we all know that takes time. Meanwhile, this is a practice that is happening in our Emergency Departments and as ED nurses, we definitely should know about them.   This is the initial reason for a push dose pressor episode on this podcast. Nurses, we are going to be the ones mixing and preparing the push dose pressors, and a good chance we will be administering it. These medications, epinephrine and phenylephrine, are extremely potent and should be highly respected when used.  It also warrants an increased awareness of the entire process - including when to use them, and what safety measures we can use to prevent medication errors.   So let’s go over some safety measures that will ensure the correct utilization of push dose pressors.    1. Mixing/Preparing Epinephrine Push Dose Pressor Let’s start with preparing an epinephrine push dose pressor - After I had released my podcast, a nurse listener, immediately brought to my attention that using pre-filled saline flushes to prepare the epinephrine push dose concentration is bad because it can lead to medication errors. I definitely argued that I don’t see the difference between using a pre-filled saline flush for a push dose pressor versus a pre-filled saline bag for a drip - as long as it is labeled properly (use concentration doses).   More responses came and a major safety issue came up that health care providers are NOT labeling their syringes after mixing - why??!!  And there has been reported errors in medication where health care providers are mistakenly pushing what they think is a NS flush syringe - but it actually has medication in them (epinephrine or other medications).   This gave me a heavy heart - and you know, I wanted to puke a little bit. I hope you all can forgive me. The last thing I would ever want to endorse is an unsafe practice, or a practice that can lead to even more errors. That being said, I will change my own practice to draw up epinephrine in an empty syringe and dilute it to a proper push dose concentration - and immediately label the syringe afterwards.   Never let that syringe out of your hands or eyesight until the label is securely on the syringe.   Epinephrine is a medication that is prone to errors to begin with.   Some additional tips on mixing:   Labeling Always label where you can still see your mL markings on the syringe - it’s important that way you know how much you are giving! This also applies to other medications like your intubation meds..   Why Use Cardiac Pre-filled Syringes? You may wonder why it is recommended to mix from a cardiac pre-filled syringe - it’s because you can guarantee the concentration (1:10000 with 10mL). Many medication rooms will have different concentrations stocked 1:1000 for anaphylaxis or 1:10000 for cardiac arrest - but both are in 1mL vials. If you were to grab the vial of Epinephrine 1:10000 in 1mL - you are supposed to further dilute that before administering.   So when your patient is crashing, to prevent thinking it even further, it’s easier to grab the cardiac pre-filled syringe because you know it will have a concentration of 1:10000 in 10mL.   Maintain Sterility When mixing, try to maintain sterility as much as possible. Remember all medications will go into the blood stream, we do not want to introduce more problems.

007 Push Dose Pressors – The Full Safety Dance

Elevate your Emergency Nursing practice. One episode at a time.

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RESUS NURSE

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