Brian Driver

@AcademicEmerMed @SAEMonline @GitaPensaMD @EMHighAK @MprizzleER @AliRaja_MD @MGottliebMD @MDaware @EMSwami @JohnCSakles @embasic Have to decide whether intubation success and safety trump patient experience. This will vary patient to patient and physician to physician. But for very critically ill patients who require intubation, success might trump experience (& pt might not remember if benzos given IM)

@AcademicEmerMed @SAEMonline @GitaPensaMD @EMHighAK @MprizzleER @AliRaja_MD @MGottliebMD @MDaware @EMSwami @JohnCSakles @embasic If NMBA given first, you could very well have a paralyzed and awake patient, but they'd be fully relaxed and intubation should be smoother. Benzos or other sedatives can be given IM ASAP. So, there's a tension between sedative first and NMBA first if the IV is tenuous.

#AEMJC question for author @brian_driver (and you!): What if you lose IV access in between administration of RSI medications? Read more in @AcademicEmerMed: onlinelibrary.wiley.com/doi/epdf/10.11… FREE ACCESS / #FOAMed

@doctalk @AcademicEmerMed @MGottliebMD @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @EMHighAK @MprizzleER In this practice, there is usually a 20-30 s delay between NMBA and sedative. Patients usually have no awareness of paralysis without sedation. Refs: doi.org/10.1016/s0952-… doi.org/10.1097/000005… doi.org/10.1007/BF0301… doi.org/10.1097/000005… ncbi.nlm.nih.gov/pmc/articles/P…

@doctalk @AcademicEmerMed @MGottliebMD @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @EMHighAK @MprizzleER Administering the NMBA before the sedative is not the same as paralyzing a patient before sedating them. There is a practice called the "timing principle" performed in the OR, where the NMBA is administered, and the sedative is withheld until weakness (ptosis or weak grip).

#AEMJC question for author @brian_driver: Where did the idea for this study come from? Read more in @AcademicEmerMed onlinelibrary.wiley.com/doi/epdf/10.11… FREE ACCESS / #FOAMed

@AcademicEmerMed @SAEMonline @GitaPensaMD @AliRaja_MD @SAEMEBM @MGottliebMD @EMHighAK @MprizzleER For several years some physicians in our dept have administered the NMBA first to attempt to avoid the occurrence of sedative-associated apnea prior to complete muscle relaxation. We wanted to study whether NMBA first was assoc with time to intubation.

@embasic @chitwngurl Steve delivered a great talk on pre-ox - excellent review of important pre-ox strategies prior to ED intubation

@MDaware @JayHineMD that’s what we took away - not to avoid ketamine for DSI - but rather to be ready/vigilant in case of complication

@getdec44 @MDaware @AnnalsofEM not sure it’s clear cut that *all* need bmp ; may be room for physician judgement

@screamingmd @MDaware @efunkEM @FLTDOC1 @DrHowieMell I don’t count polyuria as worrisome sx. Agree it should be expected

@efunkEM @MDaware @FLTDOC1 @DrHowieMell I do not if no sx and they are in ED just for glucose value- but this approach not studied

@drgeorgedavis I make sure they have proper meds and supplies, and educate as needed so that they know how to use/take them.

@FLTDOC1 @MDaware @DrHowieMell my practice: as long as the pt appears well, don’t treat unless >600 and focus on outpatient meds & good f/u

@FLTDOC1 @MDaware @DrHowieMell us too - made us wonder what benefit we were actually providing to the patients, if any

@Jeff__Riddell @MDaware @AnnalsofEM we have ongoing RCT comparing loose to tight glucose control in this patient population

@smithECGBlog @EM_ResUS @WICSBottomLine I agree. I would also say: good neuro outcomes are possible, even with prolonged CPR.

Thrombin Time is the best screening test for the contribution of dabigratran to bleeding problems #hcmca16

Check visual fields for vague eye complaints. If visual field cut in both eyes, lesion is at or behind the optic chiasm #hcmca16

#hcmca16 Post-LP HA reduced by 1) smaller needle (22g) 2) smaller CSF volume 3) bevel parallel to dural fibers 4) non-cutting needle

#hcmca16 pt has anaphylactoid reaction after eating fish? Think scombroid toxicity- histidine in improperly stored fish agonist @H1 receptor