“Emergency Reflex Action Drills” – When The Patient Unexpectedly Crashes – Help From EMCrit

Emergency Reflex Action Drills by By Mike Lauria*, Cliff Reid, and Scott Weingart from EMCrit is an excellent reminder: When things unexpectedly go bad you must have a prerehearsed plan in place that you can immediately initiate.

*Mike Lauria, prior to embarking on his formal medical training, was in Special Forces and also was a paramedic. In this post he goes over lessons learned in his past that are applicable to sudden unexpected medical catastrophes.

What follows are extracts from the post :

“Contact Right!”

In the special operations community we accepted that certain dangerous situations develop at a speed that exceeds our analytical capability. This understanding came to be by many hard-learned lessons, paid for in blood by our predecessors. As a result, our training evolved to incorporate Immediate Actions Drills (IADs).

These IADs were trained, habitual reflex action patterns to various potentially lethal, time-sensitive situations. For example, if a team was on patrol and someone started shooting at them from the team’s right flank, the immediate response was to call out “contact right”. The team would quickly lay down suppressive fire in the direction of the threat and rapidly execute a standard tactical maneuver (rehearsed dozens of times in training).

There are certain situations in resuscitation that are very time-sensitive and require immediate action. Often, the challenge is that we train people to diagnose critical, life-threatening problems the same way we teach them to diagnose routine ones. The fact is that in very stressful situations, our brains don’t function the same way they do normally. As a result, it may be worthwhile to think through these particular clinical circumstances in advance, consider the very likely causes of the situation, and train people to empirically address these issues using a fixed, reflexive action pattern.

Emergency Reflex Action Drills: Designing the Human System

Emergency Reflex Action Drills (ERADs, pronounced ē – rads) are specifically designed action sequences intended to execute clinical interventions with minimal cognitive load in the setting of marked time pressure. These drills are tailored to respond to particular situations. They are carefully developed with thought, intention, and analysis of the available literature to consider the risks and benefits. In essence, the “thinking” is done in advance so that during a true emergency the programmed cognitive and action sequence can be applied.

The authors then provide six specific examples of Emergency Reflex Action Drills (ERAD) [In order to get the most out of the authors’ post, you’ll want to review each one of the examples]:

  1. Response to Grade III or IV Cormack-Lehane View During Intubation – George Kovacs (@kovacsgj) developed an excellent ERAD in response to Grade III/IV view on direct laryngoscopy in three steps: 1) lift the occiput beyond sniffing position and align axes, 2) use external laryngeal manipulation to optimize view, 3) Use Two Hand lifting if unable to manage with one hand. Or as Scott teaches this ERAD, HEAD-NECK-HANDS
  2. Response to Sudden and Profound Hypotension – Scott uses this immediate action in response to a patient whose hemodynamics suddenly deteriorate and is peri-arrest: 1) grab an amp of cardiac epinephrine (100 mcg/cc) from the code cart 2) push 0.5 cc to maintain hemodynamics while you determine the cause for acute decompensation and develop a plan for definitive fix. CART-EPI-HALF
  3. Response to Hypoxia in the Awake Patient – Rich Levitan (@airwaycam) teaches the OOPS mnemonic to address hypoxia: 1) OXYGEN ON via nasal cannula, [At > 15 L/min as per  Ep 110 Airway Pitfalls – Live from EMU 2018]  2) PULL the jaw forward/jaw thrust 3) SIT patient up.
  4. Response to Cardiovascular Collapse in Patient on ECMO – The @EDECMO team suggest the following as immediate response to blood spraying around the room with a patient on ECMO: 1) clamp the arterial cannula 2) clamp the venous cannula 3) Prepare Epinephrine & Change Vent Settings. CLAMP-CLAMP-RESUSCITATE

My personal favorite of all these wonderful ERADS is #5 and I recommend listening to Dr. Weingart’s excellent EMCrit Podcast 16 – Coding Asthmatic, DOPES and Finger Thoracostomy, December 23, 2009.

And you’ll want to also review Dr. Weingart’s  EMCrit Podcast 15 – the Severe Asthmatic, December 8, 2009 [The podcast recommends using Magnesium in severe asthma. But in the show notes, Dr. Weingart posts an update – The 3 MG Trial (Link is to the PubMed Abstract) has shown that magnesium doesn’t help].

In one of the two podcasts, Dr. Weingart reminds us that in the severe asthmatic Bi-Pap noninvasive manual ventilation can prevent the need for intubation just as it can for severe congestive heart failure and for severe chronic obstructive pulmonary disease.

For many clinicians noninvasive ventilation is somewhat of a mystery. Fortunately, intensivist-pulmonoligist Dr. Josh Farkas has written an excellent post on the subject which should be reviewed: PulmCrit- Mastering the dark arts of BiPAP & HFNC
February 12, 2018. Review Dr. Farkas post along with Dr. Weingart’s two podcasts above while working on #5 below:

5. Response to Profound Deterioration on a Ventilator – Scott teaches this 3 part ERAD to overcome vent manipulation fixation as the patient crashes: 1) Bag with BVM (ask for a PEEP valve as soon as possible) 2) Call for Help—often fixing this problem is a 2-person job 3) Troubleshoot with DOPES. BAG-HELP-DOPES

And finally there is #6. Note that Dr. Weingart also discusses very clearly the management of blunt cardiac arrest towards the end of EMCrit Podcast 16 – Coding Asthmatic, DOPES and Finger Thoracostomy, December 23, 2009.

6. Response to Loss of Palpable Pulses in a Blunt Polytrauma Patient – The Sydney HEMS team will 1) Attempt to arrest massive haemorrhage, 2) Perform a ‘cold’ tracheal intubation, 3) Make bilateral open thoracostomy incisions, and 4) infuse packed red blood cells. STOP-TUBE-CUT-INFUSE

Additional Resources:

(1) Emergency Reflex Action Drills [Link is to the blog post]
April 24, 2018  By Mike Lauria, Cliff Reid, and Scott Weingart from EMCrit

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