Week in Review: 2/07/21

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

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

Ketamine Induced Hypotension by Steve Haywood

  • Ketamine is still a strong choice for the induction of a hemodynamically fragile patient. 
  • Ketamine can increase blood pressure by inhibiting the catecholamine reuptake channels.
  • If the catecholamine supplies are exhausted or the receptors are desensitized this inhibition may not matter.
  • In this hemodynamically fragile patient we should always anticipate post intubation hypotension regardless of what induction agent we are use.
  • Preparation for post intubation hypotension should include obtaining good IV access, resuscitating before intubating, and setting the BP cuff to cycle frequently. 

All Things Being Equal…Physician Gender Doesn’t Matter in Trauma Resuscitations by Zaf Qasim

  • In this study looking prospectively at team leadership performance and patient outcomes (saying this louder for the people in the back) – there is no support for previously reported gender-based differences in team leadership. 

  • Although our focus should be on ensuring that all our trainees (whoever they are) are educated in a manner where they are empowered to be effective and safe team members and leaders, we must acknowledge that gender issues in medicine continue to raise their ugly head…the fact that this continues to appear in the literature is a case-in-point. 

  • Our entire team implores you to tackle this issue head-on and call it out when you see it.

Consequences of the Denervated Heart by Colin McCloskey 

  • Cardiac transplant leads to interruption of the nerve supply to the heart
  • These patients cannot feel angina
  • They will not have an appropriate heart rate response to hypotension or hypovolemia
  • Cardiac medications will have atypical effects, with vagolytics being ineffective and adenosine having exaggerated effects.

A Life Saving Drug-Drug Interaction by Rachel Rafiq

  • A well-described drug-drug interaction exists between carbapenem antibiotics and valproic acid and therefore the combination should be avoided outside of a toxicological circumstance
  • Meropenem and ertapenem have been documented to reduce serum VPA levels up to 90% and therefore may be a unique method to treat valproic acid overdose  
  • The benefits of a short course of antibiotics may outweigh the risks related to antimicrobial stewardship
  • Carbapenems should not replace standard therapy but may be an excellent adjunct 
  • No specific Meropenem or Ertapenem dosing strategy has been recommended 

Engaging The Socially Distanced Learner by Zack Repanshek

  • The bottom line when trying to maximize engagement in virtual learning is to limit the time your learners are staring at a static slide on a computer screen and leverage opportunities for group participation.

High Flow Nasal Cannula Therapy in Bronchiolitis by Tammy Dutch

    • HFNC can help support increase respiratory demand thus decreasing retractions
    • HFNC hydrates mucus helping to facilitate mucociliary clearance allowing for easier suctioning 
    • Be sure to set appropriate settings and use the appropriate cannula

The Rule of 2’s by Shyam Murali

  • Two types of respiratory failure
    • Type 1 – Hypoxemic
    • Type 2 – Hypercarbic 
  • Two ways to approach fixing each 
    • Type 1 
      • Increase FiO2 
      • Increase Mean Airway Pressure
    • Type 2 
      • Increase Tidal Volume 
      • Increase Respiratory Rate
  • Two Types of Noninvasive Positive Pressure Ventilation
    • CPAP
    • BPAP

How to Place a Subclavian Line With Ultrasound by Haney Mallemat

  • Internal jugular vein catheters have increased risks of infection and DVTs; consider the subclavian vein for central venous catheters instead!
  • Use ultrasound for placement of the subclavian vein catheters
  • Your target may actually be the axillary vein
  • Use the long axis view on the ultrasound to reduce the chance of going through the back wall of the vein
  • Check out the video for more tips and tricks!


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