Week in Review: 1/24/21

by Melina Alexander January 24, 2021

Reading Time: 2 minutes

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

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

Peak pressure: This is the pressure that is generated by the ventilator to overcome BOTH airway resistance AND alveolar resistance.
Plateau pressure: This is the pressure that is essentially left over in the lung after the tidal volume has been delivered.
High Peak pressures and normal plateau indicate an issue with elevated resistance
High Peak and high plateau pressures indicate an issue with compliance

There are no papers to my knowledge that have compared IO sites (humeral vs tibial) in cardiac arrests. Additionally, most IV’s in American prehospital system are placed in the upper extremities, and most IO’s are placed in the lower extremities. It would be useful to compare outcomes of IVs vs. IOs that are placed on the same body region.
Finally, There doesn’t seem to be a significant data set that randomizes IO vs. IV. In my own experience, a well placed humeral IO flows just as well as a peripheral IV, and it’s relatively simple in most patients to place.

Of course, sometimes you’re going to just activate your snatching hands and take over that airway if it’s the right thing for the patient, but by reviewing your plan, taking a pause, and asking what you can do to help, you can help your resident become more confident and successful when intubating while simultaneously building trust with your learner and team.

The Religion of Subspecialties by Sharad Patel and Tapan Kavi

Tribalism exists across all spectrums of human life.
Physicians are not immune to the tribalistic tendencies.
In-group and Out-group hostilities of medical subspecialties likely diminishes the quality of patient care.
Improving physician mental health may reduce the toxic behaviors that stem from tribalism.

Standard treatment of clostridial myonecrosis or “gas gangrene” is aggressive surgical debridement with concurrent broad spectrum antibiotics.
With inadequate source control from surgery alone and where logistically possible, adjunctive HBOT should be strongly considered.
There are well demonstrated physiologic mechanisms by which HBOT can counteract the injurious effects of alpha and theta toxins.
Retrospective evidence suggests improved mortality and amputation rates when HBOT is added as an adjunctive therapy for Clostridial myonecrosis.

IPV/Metaneb both utilize High Frequency Oscillatory therapy in conjunction with aerosol therapy to facilitate secretions from smaller airways to larger airways where it can then be expectorated or suctioned. The use of oscillatory therapy also helps promote lung expansion
No major difference has shown between choosing over the other as the method of therapy
Both therapies have shown to be helpful in patients with chest wall complications

Carefully consider whether the patient in front of you truly needs an arterial line before placing one
Make sure your whole team is aware of exactly why the art line was placed
Despite widespread use of arterial lines, there is no evidence that using them improves outcomes in the ICU

Nerve blocks are another tool in your pain control toolbox.
Remember to have your local protocol for lipid rescue accessible to treat any adverse symptoms of LAST syndrome.

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