Week in Review: 1/10/21

Reading Time: 3 minutes

St. Vincent's Emergency Medicine Resident, PGY-1

For some spaced repetition, here’s a review of this week’s content:

Ketamine is widely believed to have a hemodynamically supportive profile which has been demonstrated in multiple studies.
Two recent database studies challenge this assumption with higher rates of hypotension in the ketamine groups when compared to etomidate.
Given the conflicting data, a well designed prospective study is needed to shed light on ketamine’s hemodynamic profile during intubation

When faced with an injury requiring a time-critical intervention, as in our case, go for the technique that will provide the most bang for the buck.
The evolving evidence is clear – a clamshell approach to RT can be made in about the same time as the traditional anterolateral approach, and importantly allows better access to thoracic structures that may be injured. So if you find yourself in this situation (and have the system support) – go for the clamshell.

The Digital Educator by Zack Repanshek

The first post of “The Virtual Educator” series, we will discuss some basic concepts toward mastery of Zoom.
Basic concepts of Zoom including the Chat Bar, The PowerPoint Window, and Annotate
More to come on how to master becoming a Digital Educator!

Your loved ones love you, but the garbage doesn’t take itself out. Your paycheck/profession does not equate to a “hall pass”. They are working hard at home and/or at their own jobs too.
Communicate your schedule to those you love. Find a way to make it accessible and up-to-date.
Some simple ways to be present when you are absent:
- Participate in chores (there is no dishwashing fairy).
- Be proactive with thinking about home/relationship needs.
Mealtime is a team sport, even when you aren’t there. If you can’t cook together, think about lending an assist (even if that just means calling for pizza ahead of time). Also consider:
- Helping with meal planning
- Organizing nights out/take-out nights
- Preparing a meal in delayed fashion (e.g. slow-cooker meal)
Preparing a mise en place with a recipe you selecte

Pressure, flow, and volume scalar waveforms are real-time breath to breath patient respiratory pathophysiology.
Understanding how to read and interpret scalar waveforms helps clinicians optimize ventilation and patient synchrony while decreasing injury.
Be aware of rain out to prevent artifact on your waveforms.

When using cefepime, ensure it is dosed appropriately based on renal function.
CIN occurs not only in patients with renal impairment, but also in patients with no renal impairment and those receiving appropriate cefepime dosing.
Frequent neurological assessments are warranted for all patients receiving cefepime, especially those with risk factors for CIN such as renal impairment, increased age, receipt of high cefepime doses, preexisting brain injury, and patients who are likely to have increased CNS penetration.
CIN manifests itself roughly 4 days after initiation of cefepime.
If CIN is suspected, cefepime should be discontinued immediately and another agent should be utilized. In life threatening cases, dialysis can be used.
Recovery from CIN is roughly 2 days after discontinuation of cefepim

Every ICU physician needs to be comfortable dealing with the end of life
SPIKES is a great framework for the end of life/goals of care conversation, with some important caveats
- You often do not have the luxury of time in creating therapeutic bonds with your patients or their families; you must find a way to be empathetic, warm, understanding, and still deliver complicated clinical information in a simple way for everyone to understand
Actively listen to what is being said – if a family member wants to share a story, let them!
Do not fear silence
Always follow through on the mutually agreed upon strategy
Be kind. This is often the worst moment in a family’s life. You are forever going to be associated with the death of their loved ones. You have the power to make this experience as atraumatic as possible if you approach the conversation in the right way
These conversations can be traumatic for you, your trainees, the nurses, and all other members of the ICU team. Take time to debrief and reflect if you have it. Promote open communication and don’t shame anyone who feels emotional about these conversations.

Go With the Flow by Harman Gill