Ectopic Algorithm Snippet

Key Points

In hemodynamically stable patients, the history and physical are insufficiently accurate to either rule in or rule out ectopic pregnancy.  The threshold should be very low to enter a patient with early pregnancy and symptoms or signs potentially referable to ectopic pregnancy into a rule out ectopic process.

In contrast to what most of us were taught, the index beta HCG measurement does not discriminate among ectopic pregnancy, failed/failing intrauterine pregnancy, and early/healthy intrauterine pregnancy with sufficient accuracy to guide decision-making. Put more simply, the beta does not help you. If the ultrasound shows no IUP or ectopic, do not be reassured by a low beta and do not be alarmed by a high beta. The patient may have a healthy IUP, she may have a nonviable IUP that is miscarrying or will miscarry, or she may have an ectopic pregnancy; the beta doesn’t make any of these three diagnoses more or less likely enough to be a useful test to us, on the index visit. This is not controversial, the evidence is plentiful [1, 2, 3, 4, 5, 6, 7], and ACEP’s recent clinical policy states at a Level B recommendation, “Do not use the beta-hCG value to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound.” If the beta is a million zillion, feel free to diagnose molar pregnancy.

If IUP is confirmed by ultrasound, measurement of quantitative beta is unnecessary. If ultrasound shows no evidence of IUP or ectopic, a quantitative HCG level should be sent but the result is not important for this visit–it is useful in comparison to the beta drawn in followup.  A low beta should never be used as a reason to forgo pelvic ultrasound, and a high beta should never be used as a reason to initiate treatment for ectopic pregnancy (in a stable patient). The concept of the discriminatory zone is obsolete and has no value to emergency clinicians [1, 2, 3].

There are a variety of abnormal early pregnancy conditions, and the terminology is confusing. Threatened abortion refers to a patient with a confirmed IUP who has bleeding or pain; these patients are not at risk for ectopic pregnancy and threatened abortion should not be used as a diagnosis for patients with pregnancy of undetermined location. Similarly, patients with missed, inevitable, incomplete, and complete abortion by definition to do not have ectopic pregnancy, and, like threatened abortion, these conditions are generally not dangerous to mom. Often, these diagnoses can only be made after repeat ultrasound and beta measurements. I liken these diagnoses to migraine, tension, cluster, and other primary headaches: the role of the emergency clinician is not to diagnose a benign headache syndrome, it is to exclude dangerous causes of headaches. Confident as you may be that your patient without a sonographic IUP is having some variant of miscarriage and not an ectopic, to make that diagnosis prior to the beta falling to zero (or the passing of what is unequivocally products of conception, i.e. has a human form or characteristic features under a microscope) is unwise. Septic abortion, while not an ectopic pregnancy, is dangerous, and patients with early pregnancy and fever, unwell appearance, or significant uterine tenderness should be managed with this condition–which generally requires prompt surgical uterine evacuation in addition to parenteral antibiotics–in mind.

Most patients who present to the ED with bleeding or pain in early pregnancy are primarily concerned about the viability of their pregnancy, while the emergency clinician’s priority is excluding the presence of a dangerous condition–in this case, mainly ectopic pregnancy. It is important to recognize and address this discordance.  Attempting to determine if the pregnancy is likely to succeed or fail on the index visit is imprudent in most cases, but not acknowledging your patient’s concerns is equally imprudent.

“Using the ultrasound, I don’t see where your pregnancy is. Most likely, you have either a normal pregnancy that I can’t see, or you’re having a miscarriage; we can’t tell, and there’s nothing you or anyone can do to change your course other than having a healthy lifestyle and taking care of yourself. But neither of these situations is dangerous to you and our role in the emergency department is to make sure that your symptoms aren’t caused by a problem that is dangerous to you, most importantly, a pregnancy in the wrong location such as the fallopian tubes. And since I don’t see where your pregnancy is today, we need to repeat the ultrasound the day after tomorrow. If you have more bleeding, or more pain, or feel faint or pass out, or develop a fever, come back immediately, we’re here 24/7.”

 

Who does the ultrasound?

Much practice variability exists around who performs the ultrasound–the emergency clinician, obstetrician, or radiologist–in different rule out ectopic scenarios. Emergency physician-performed ultrasound has been demonstrated to be accurate in this context, and it is reasonable and appropriate for emergency physician-performed ultrasound to be used as the primary imaging modality in a rule out ectopic paradigm, especially when the emergency physician has demonstrated proficiency in pelvic ultrasound and the study is performed under a structured departmental ultrasound QA process. But sometimes an ectopic pregnancy can look like an IUP, and calling what isn’t an IUP an IUP is a very dangerous mistake (don’t neglect to evaluate the myometrial mantle all around what you think is an IUP).  Also, we generally rule out ectopic by ruling in IUP, and when an IUP is definitively identified in a patient not at high risk for ectopic or heterotopic pregnancy, ectopic pregnancy has been reasonably excluded. However, in a patient without sonographic IUP, the second goal of imaging is to look for evidence of ectopic pregnancy, and these findings, often in the adnexa, require more ultrasound skill.

As usual, the most important strategy to manage physician risk is to decide as a department and institution how these patients will be managed. Reasonable approaches include, in order of decreasing emergency clinician risk (and increasing patient inconvenience):

a. Discharge the patient after emergency physician-performed ultrasound either with a diagnosis of intrauterine pregnancy and routine followup, or with a diagnosis of pregnancy of undetermined location, strict ectopic precautions and urgent followup, based on the results of the emergency physician-performed ultrasound.

b. Discharge patients who do not have ectopic risk factors and have PUL after emergency physician-performed ultrasound with ectopic precautions and urgent followup; arrange immediate specialist-performed ultrasound for patients with ectopic risk factors who do not have an IUP identified by the emergency clinician. This is the strategy I use.

c. Arrange immediate specialist-performed ultrasound for all patients who do not have IUP identified by the emergency clinician.

d. Arrange immediate specialist-performed ultrasound for all patients who enter into the rule out ectopic flow.

There are other approaches and gradations within these approaches; for example, if you usually discharge a rule out ectopic patient after your bedside ultrasound but have a patient you are more concerned about than usual, but don’t have access to specialist ultrasound or assessment, have the patient return for repeat assessment not in 48 hours but in 24 or 12 hours.

 

Rhogam

The use of Anti-D rhesus prophylaxis in early pregnancy is controversial, because “There are insufficient data available to evaluate the practice of anti-D administration in an unsensitised Rh-negative mother after spontaneous miscarriage. Thus, until high-quality evidence becomes available, the practice of anti-D Immunoglobulin prophylaxis after spontaneous miscarriage for preventing Rh alloimmunisation cannot be generalised and should be based on the standard practice guidelines of each country.”

The use of Rhogam for threatened abortion or pregnancy of undetermined location is even less likely to be beneficial than in cases of diagnosed miscarriage, which was the subject of the quoted Cochrane review. ACOG recommends it “after a first-trimester pregnancy loss” and suggests it “be considered” in cases of threatened abortion, while British guidelines state, “Do not offer anti-D rhesus prophylaxis to women who receive solely medical management for an ectopic pregnancy or miscarriage, or have a threatened miscarriage, or have a complete miscarriage, or have a pregnancy of unknown location.” ACEP chimes in with their Level B recommendation “Administer 50 μg of anti-D immunoglobulin to Rh-negative women in all cases of documented first trimester loss of established pregnancy” and Level C “Consider administration of anti-D immunoglobulin in cases of minor trauma in Rh-negative patients.”  See SMART-EM‘s treatment of the subject for details. If you don’t use Rhogam routinely in threatened abortion, most of these patients can return home to their loved ones immediately if IUP is identified, without bloodwork, and even, some say, without a pelvic exam [1, 2].

 

Followup

Ideally all patients with pregnancy of undetermined location would be seen by an obstetrician within 48 hours for repeat exam, ultrasound, and serum beta. If the only option in your environment is for the patient to return to the ED, if IUP is not identified on the repeat visit, have a low threshold to at least discuss the case with an obstetrician. Interpreting beta trends and deciding on therapies like methotrexate, or uterotonic agents, or dilation and curettage, is ideally in the domain of obstetrics and not emergency medicine.

 

Rule Out Ectopic Algorithm (Screen Version)

Rule Out Ectopic Algorithm (Print Version)

 

Thanks to Sigrid Hahn and Phil Andrus for their erudition.

 

Bonus: amazing/bewildering vaginal bleeding algorithm I created as a medical student many years ago, demonstrating outdated strategies for rule out ectopic, among many other outdated strategies.

There was a period in the history of emergency medicine when cricothyrotomy was the primary airway management strategy for all patients in cervical spine precautions. We have since learned that most of these patients can be intubated orally, but in the intervening years have lost our nerve when it comes to using the neck for airway access. Today, everyone agrees that the most important error around emergency cricothyrotomy is that it is performed too late [1, 2, 3]. An unsuccessful cricothyrotomy performed at the right time is defensible; a successful cricothyrotomy performed too late is indefensible. Both lead to terrible outcomes: one is good, defensible care, the other is poor, indefensible care. The pivotal element in emergency surgical airway decision-making is giving yourself permission to initiate the procedure before the patient is dead.

Guidewire

 

The Cricothyrotomy Menu

There are a variety of strategies for accessing the trachea via the neck and the terminology is confusing. Open cricothyrotomy, often referred to as surgical cricothyrotomy, is using a knife to cut a hole in the cricothyroid membrane and placing a tracheostomy tube or endotracheal through that hole. Several techniques have been described, including the no-drop technique, the rapid four-step technique, and the scalpel-bougie technique.

Percutaneous cricothyrotomy is a term usually used in distinction to surgical or open cricothyrotomy, implying a less invasive approach. Percutaneous cricothyrotomy facilitates the placement of a tracheostomy or endotracheal tube in the trachea by using either a Seldinger tube-over-dilator-over-wire technique, or a tube-over-trocar device [1, 2]. Most emergency physicians are referring to the Seldinger technique when they use the term percutaneous cricothyrotomy.

Though a needle is used in the Seldinger technique, the term needle cricothyrotomy usually refers to a less definitive procedure where a comparatively small cannula, such as a 14g angiocath, is placed into the trachea and oxygen is insufflated under pressure through the cannula; this is called transtracheal jet ventilation when a special high-flow device is used, though a bag-valve-mask is more likely to be available, if less effective, and several hard to remember maneuvers are commonly proposed that allow a BVM to be adapted for this purpose.

Wire In Trachea Readiness Technique

For patients who suddenly and unexpectedly cannot be intubated or oxygenated, the weight of evidence and opinion seems to favor an open technique [1, 2, 3, 4, 5], which appears to be faster than a percutaneous approach, more likely to be successful for those who don’t perform the procedure often (i.e. everyone), and would be used to rescue a failed percutaneous attempt. Smart people disagree on this point, however. Certainly, the goal in these scenarios is to establish oxygenation as quickly as possible by whatever means necessary, and that will differ based on provider, patient, and setting. Have a plan that works for you in your environment.

Many patients who cannot be intubated orally do not suddenly and unexpectedly crash, however. The need for a surgical airway can present itself as a land mine that explodes in front of you as you walk to your mailbox in your bathrobe, but also as a land mine that explodes as you carefully traverse a known minefield in a tank. Of course every emergency intubation is a minefield, and being cognitively and materially prepared for failure of intubation and failure of ventilation at the outset of every case is one of the characteristics of the airway expert. But while we have many options for plan A and plan B, there is still only one plan C – when intubation fails, and oxygenation fails, plan C is cricothyrotomy. Since it is clear that the most important surgical airway error is that it is delayed, several airway management paradigms [1, 2, 3] have recently emerged that explicitly encourage providers to prepare for and properly initiate cricothyrotomy.

In Scott Weingart’s CricCon taxonomy, the highest alert posture is to cut the skin and find the membrane, so that if the need arises, incising the membrane and placing the tube is simple. Most emergency practitioners, however, are uninterested in cutting the neck. On the other hand we are perfectly happy to put wires and tubes in the neck, and do it all the time in the internal jugular vein. Here lies the role of percutaneous cricothyrotomy: not as a crash technique, but as an alert posture, a readiness maneuver: when the likelihood of requiring a surgical airway is sufficiently high, place a wire in the trachea.

Placing a wire in the trachea feels more like inserting a central line than cutting the neck. Feel free to use ultrasound. [1, 2, 3] The strength of the wire-in-trachea approach is that it lures the practitioner into preparation and makes timely performance of cricothyrotomy more likely by breaking the procedure into agreeable steps. Inclination via incrementalism.

There are at least two scenarios in which wire-in-trachea readiness technique would be used:

a. An almost crash expected very difficult laryngoscopy, such as an angioedema patient who requires an airway not this very second but urgently.  If the patient is cooperative, wire is placed after rapid local anesthetic infiltration as preparations are being made for awake laryngoscopy vs. RSI. If uncooperative, wire is placed immediately after induction (concurrent with preoxygenation if using a delayed sequence strategy), just before laryngoscopy, or as laryngoscopy is beginning. This is basically an enhanced double setup.

b. In the midst of a can’t intubate, can ventilate situation. This occurs relatively commonly: laryngoscopy has failed, but LMA or bag-mask ventilation is effective, then the second laryngoscopy attempt fails, but ventilation remains effective, and then the third attempt fails, and you feel like you’re running out of tricks/tools. And you know that with every airway attempt, the glottis becomes a little more swollen, the airway gods–who have until now granted you the gift of ventilation–their patience is a little more tested, and the prospect of can’t intubate, can’t ventilate looms. So after a few failed oral attempts, while the patient is being ventilated, place the wire, then go on with as many further attempts as you want, knowing that if and when ventilation becomes ineffective (or if you have other patients to see and want to move on), cricothyrotomy is straightforward.

Logistics

Percutaneous cricothyrotomy kits are expensive and often stocked in small numbers. To utilize the wire-in-trachea readiness technique, use the needle/syringe/wire from a central line kit. Fill the syringe halfway with water/saline so that tracheal location of the needle can be confirmed by the bubbling of aspirated air.

Have your unopened percutaneous cric kit at the bedside, and when needed, 1) open the kit 2) stab the skin with the scalpel 3) slide the tracheostomy tube-over-dilator into the trachea 4) pull the wire and dilator 5) inflate the cuff 6) ventilate. Don’t forget to load the tracheostomy tube onto the dilator if not pre-loaded in your kit.

Step 2 is important: an aggressive stab must be made on the skin, along the path of the wire, similar to central line technique but larger, to accommodate a larger device.

Step 3, inserting the tube-over-dilator, is facilitated, like everything else, by the application of sterile lubricant. Use a firm twisting motion.

If oral or nasal access is successful and cricothyrotomy isn’t needed, simply pull the wire. Put a band-aid on the site; this will serve as evidence of a disarmed land mine.

emupdates ETI Plan ABC

 

Thanks to Rob and Scott for helping me develop this idea.

snippet

 

Vector image for screen viewing

Acrobat document for printing

 

References:

• 1 Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M. Videos in Clinical Medicine: Abscess Incision and drainage (video). N Engl J Med 2077; 357:e20.

• 2 Danby FW, Margesson LJ. Hidradenitis suppurativa. Dermatol Clin. 2010Oct;28(4):779-93.

• 3 Orman, Rob. Perianal Abscess. ERCAST, Jan 2011.  http://ercast.org/perianal-abscess

• 4 Schwarz RJ, Shrestha R. Needle Aspiration of Breast Abscess. Am J Surg. 2001;l 182(2):117.

• 5 Kronfol R, Downey K. Technique of Incision and Drainage for Skin Abscess. UpToDate Online. May 2011.

• 6 Wilson W et al.  Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association and others. Circulation. 2007 Oct 9;116(15):1736-54.

• 7 Roberts, James R. Clinical Procedures in Emergency Medicine, 5th ed. 2009.

• 8 Liu C, Bayer A, Infectious Diseases Society of America, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylo- coccus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55.

• 9 O’Malley GF, Dominici P, Giraldo P, Aguilera E, Verma M, Lares C, Burger P, Williams E. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009 May;16(5):470-3.

• 10 Schmitz GR. How do you treat an abscess in the era of increased community-associated methicillin-resistant Staphylococcus aureus (MRSA)? J Emerg Med. 2011 Sep;41(3):276-81.

• 11 Walraven CJ, Lingenfelter E, Rollo J, Madsen T, Alexander DP. Diagnostic and therapeutic evaluation of community-acquired methicillin-resistant Staphylococcus Aureus (MRSA) skin and soft tissue infections in the emergency department. J Emerg Med. 2012 Apr;42(4):392-9.

 

Tetanus recommendations

 

For abscess I&D, most of us haven’t been thinking about antibiotic prophylaxis in patients at risk for infective endocarditis. According to my interpretation of table six of this guideline, we should be. “Antibiotic prophylaxis is reasonable for procedures on respiratory tract or infected skin, skin structures, or musculoskeletal tissue only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE (Table 3).”

The Emergency Department Double Setup

October 25th, 2012
by reuben in airway

 

The double setup is an airway management strategy conventionally carried out in the operating room, in a stable or relatively stable patient who requires a definitive airway but is anticipated to be very difficult to intubate orally. An otolaryngologist or other surgeon fully prepares to perform a cricothyrotomy or tracheotomy–patient prepped, all equipment laid out, sterile gown and gloved, scalpel in hand–and then gives the anesthesiologist the nod, at which point the patient is induced and orotracheal intubation is attempted. If unsuccessful, anesthesia nods to surgery, who proceeds with a neck incision.

Emergency physicians are trained to manage difficult oral airways and perform cricothyrotomy–how does the double setup apply to our environment? Once the decision to intubate has been made and preoxygenation has been initiated (don’t forget the nasal cannula), ask two questions: How urgently must this patient be intubated? How difficult do I predict this airway to be?

 

Scenario 1: Must intubate immediately, very scary airway.

Some patients need to be intubated right now, and some patients who need to be intubated right now also are predicted to have difficult airways. The paradigmatic examples of this stressful situation are the dynamic airway insults: patients with bullets, bites or burns (neck trauma, anaphylaxis, airway burn or caustic exposure) who are already showing signs of airway embarrassment. The proper mentality in these cases is this patient is going to require cricothyrotomy, but I’m going to attempt orotracheal intubation, just to make sure. There is no time for a fancy airway assessment or fancy preparations, these patients are a test of your department’s, and your own, usual state of readiness. Patients with dynamic airways should be induced and paralyzed, because intubation will get harder with each passing minute–RSI gives you optimal conditions, as quickly as possible. Once the tools you need to perform cricothyrotomy are at the bedside, use the orotracheal technique that, in your hands, will give you your best shot at first pass success, as quickly as possible. Video laryngoscopy is a good choice. As soon as your first pass fails and not one second later, attempt ventilation (I suggest you move straight to an LMA), but you have accepted that there is a good chance that this is also unlikely to succeed and that the next step is to cut the neck. You must give yourself permission to initiate a surgical airway early in this group. An unsuccessful cricothyrotomy performed at the right time is defensible; a successful cricothyrotomy performed too late is indefensible. Both lead to terrible outcomes, one is defensible, one indefensible. Scenario 1 is an anesthesiologist’s technique compressed into an emergency physician’s timeline.

 

Scenario 2: Must intubate immediately, no difficult airway features. 

Lots of ED patients fall into this category, perhaps the most typical is the CNS catastrophe who presents with a GCS that can be counted on one hand. Like scenario 1, the airway attempt must proceed without extensive preparation, but both orotracheal intubation and ventilation are more likely to be successful, and this procedural reserve affords you a more measured approach. Be mindful, however, that your brief airway assessment may mislead you, and that you never know what you’re going to get when you put in the laryngoscope. You therefore have decided, before you push drugs and put in the laryngoscope, what you will do when laryngoscopy fails, and what you will do when ventilation fails, and you have the materials at the bedside to do it. Experienced emergency providers recognize procedural reserve as a luxury that the patient can revoke immediately and unpredictably, and are thus ready to transition to a scenario 1 type approach every time they push a paralytic.

 

Scenario 3: No urgency to intubate, very scary airway. 

When you have time to intubate, you are swimming in the anesthesiologist’s ocean and you need to use a different stroke; in fact swimming like an anesthesiologist is mostly about wearing several life jackets and surrounding yourself with lifeguards. This scenario might involve a patient with a fixed flexion deformity of the cervical spine who is slowly decompensating from a pneumonia, or a patient with an airway tumor who just took 20 long-acting diltiazem tablets and needs gastric lavage. Calling an anesthesiologist is reasonable in these cases and certainly is the right answer on an oral board exam, but an anesthesiologist may not be available (and certainly will not be available on the boards).

The approach for these patients centers on being cognitively and materially ready for plan A, B, C, and D and on awake technique. It’s also nice to have a few friends at the bedside. Exactly what is plan A-D is up to you, as long as these plans are carefully prepared, and one of them is cricothyrotomy, if the patient cannot be intubated or ventilated. This picture demonstrates an example plan A, B, C, and D and a variety of best practice points.

The patient has a variety of congenital cognitive and anatomic anomalies, was very uncooperative and required intubation for emergent MRI. He is known to be a very difficult laryngoscopy. Our plan was to use an awake technique using IM ketamine sedation to augment local anesthesia.

1. Plan A is video laryngoscopy. The intubator (in the middle) made his best attempt but could not visualize the vocal cords, so without removing the device, handed off the video laryngoscope to the assistant on the patient’s left, who was already performing suction.

2. Plan B is flexible endoscopy, which is ongoing. Note that the operators are at this point using both video screens (video laryngoscope and flexible endoscope) simultaneously.

3. The second assistant on the patient’s right has access to the equipment tray and is also the designated surgical airway operator.

4. The neck is marked, and the site has been infiltrated with lidocaine and epinephrine. The more likely is cricothyrotomy, and the more time you have to prepare, the more advanced your surgical airway preparation should be.

5. The second assistant is using his finger to pull on the right corner of the mouth. This under-utilized technique really opens things up.

6. The usual suction (in this case, the second suction) under the patient’s right shoulder is available to either the intubator or second assistant. The flexible endoscope used in this case does not have suction capability, which made the need for suction on either side more likely.

7. The head of the bed is at 30 degrees.

8. The bag-mask is on the patient’s abdomen. A common mistake is to leave the bag-mask behind the operators, hanging off the oxygen tubing, so that as the saturation is dropping, someone who is already freaking out and tangled in wires and tubes has to perform a complex dance move to get at the device.

9. The intubating LMA is ready to be inserted if emergency ventilation is required. This is our Plan C. Plan D is cricothyrotomy (either carefully if Plans A/B/C have failed but oxygenation is adequate, or quickly at any moment if intubation and oxygenation fail).

10. A variety of tubes and blades, as well as oral and nasal airways.

11. The medications and tools we used to anesthetize the airway.

12. Post-intubation equipment.

13. The ventilator is on standby, connected to end-tidal CO2 (not visible) and programmed with patient-appropriate settings.

14. This container holds our supply of bougies and is sadly empty. There is a bougie on a stand behind the video laryngoscope, not visible but easily accessible to the assistant on the patient’s left.

15. Don’t forget to use a checklist.

 

Scenario 4: No urgency to intubate, no difficult airway features. 

Here we’re talking about the slowly worsening guillain-barré patient, or the patient with the small subdural that the receiving hospital has asked you to intubate for transport. Seems like low risk, and it is low risk, for the patient. But these cases are actually higher risk for you, because when a patient arrives in extremis, your hand is forced and if it doesn’t go well, it’s harder to hold you responsible. In a well patient with normal anatomy who needs to be intubated, you are again in anesthesiologist territory, and you are potentially held to the higher standard of an anesthesiologist, who gets called into the chief’s office when the patient wakes up with a chipped tooth. These are great cases to practice your awake technique; you might find that you don’t mind swimming with a life jacket every once in a while.

 

 


The Usual State of Readiness

September 26th, 2012
by reuben in heuristic, resus

 

Emergency providers are routinely called upon to react to complex scenarios that demand specific life-saving maneuvers, immediately and without warning.  The most important impediment to performing well in these situations is your own catecholamines, and the most important catecholamine reduction strategy is preparation. The extent to which you are prepared to immediately react is your usual state of readiness, and it has two parts: cognitive and material.

Cognitive readiness requires that you consider emergency scenarios and decide on a plan. This starts with a textbook (by textbook I of course mean the internet) and reading what others think you should do in a given emergency scenario. The hard part of cognitive readiness is keeping up with the endlessly changing, endlessly disagreeing opinions, and deciding how to shape them into a plan that you like and that works for you in your environment. Logistics are key.

As medical knowledge expands forever faster, perhaps the most important knowledge of all is knowing what you need to know, and knowing what you can look up. This is not an either/or so much as a spectrum of how close information needs to be to your brain. There are plans that have to live in your brain (management of a completely obstructing airway foreign body), facts that you can take 30 seconds to look up (weight-based dose of atropine), and lists that you can review at your desk (the differential diagnosis of anisocoria). Memory fails when catecholamines are high; planning for emergency scenarios involves the development and deployment of emergency references. Your emergency references must be instantly available, instantly familiar and navigable, and damn reliable. Your plan for emergency scenarios takes into account how close aspects of that plan need to be to your brain and incorporates your emergency references.

As you develop cognitive readiness, the plans you develop for emergency scenarios start with a textbook but proceed in your imagination. I call this invisible simulation, and I find that I do a lot of it in the shower. The more you invisibly simulate emergency scenarios, the more likely the demand to immediately act will be met with calm. It is the combination of recognizing when to act immediately, and doing so calmly, that is the defining characteristic of an emergency professional.

Material readiness is simpler than cognitive readiness but often neglected. Material readiness is having the equipment you need, when you need it, where you need it. Nurses and technicians are often charged with this responsibility, however, when you need suction and it’s not there, the technician being reprimanded later does not get the blood out of your patient’s airway. You will do well to make a habit, at the start of every shift, of verifying that the most important equipment is ready and in a location known to you.

It might seem like a daunting task to cognitively and materially prepare for all the scenarios that might call for immediate action, after all, anything could roll through the doors at any time, right? Well, yes, but not really.

Asphyxiation. We focus on airway preparation for good reason. The best time to go through your airway checklist is before the patient arrives. Of particular interest is the scalpel. It has been said (by me) that there are two kinds of emergency physicians: those who always carry a scalpel in their pocket, and those who will, later on in their career, always carry a scalpel in their pocket.

Suffocation. Your adrenals will appreciate it if you have a well-rehearsed plan for managing the severe asthmatic. Also, having the capability to immediately initiate noninvasive ventilation–without calling for a machine, mask, or respiratory therapist–is worth fighting for. When you are forced to intubate a patient who could have been managed with NIV, you have done your patient a disservice.

Exsanguination and serious trauma. Do you know how to get your hands on uncrossmatched blood immediately? Do you have a good sense of the key interventions to consider in the first few minutes of a trauma resuscitation?

Cardiac arrest. Do you know exactly how to use your defibrillator? What about if the paddles or pads are disconnected? Can you initiate emergency pacing? Do you have a command of ACLS pulseless arrest, or your own algorithm? Do you know how to lyse a diagnosed or strongly suspected pulmonary embolism in cardiac arrest? Do you have a plan for treating cardiac tamponade? For tension pneumothorax, all you need is your scalpel and your finger.

Difficult access. Do you know where your IO device is and how to use it?

The uncontrollably violent patient. Do you know how to activate the highest alert to hospital security? Do you know what drug to use if you only have one shot?

Anaphylaxis. Do you know exactly which preparation of epinephrine to use and how much? Also see asphyxiation, above.

Status epilepticus. Do you have a clear set of priorities when managing the seizing patient? Which drug are you going to reach for first, and what dose? What if you don’t have an IV/IO?

Contamination. Do you know where all your personal protective equipment is, including those fancy masks? How you will make a patient covered in something dangerous safe to bring into your department?

Poisoning. How do you access your antidotes (digoxin immune Fab, lipid emulsion, hydroxocobalamin, etc)?

There are other scenarios that require immediate action, but start with these ten. Be warned that spending too long in the shower will upset your roommate.