Week In Review: 10/17/21

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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:

What’s in a Wave(form)? Utilizing End Tidal Capnography for More Than Intubation Confirmation by Komal Parikh

  • Waveform capnography can tell you a lot about a patient, and it is extremely useful for continuous monitoring of intubated patients. 

Mechanical CPR for OHCA by Simon Taxel 

  • The use of MCPR devices in prehospital resuscitation of OHCA is increasing.

  • The currently available evidence suggests that the outcomes associated with MCPR compared to standard CPR for OHCA are the same or worse.

  • If a robust team of highly trained prehospital resuscitationists is available, then standard CPR is more efficacious for on-scene management of OHCA than MCPR.  

  • In situations where there are limited personnel and resources, or the patient must be transported while still in cardiac arrest, MCPR may be more effective than standard CPR but more research is needed.  

VV-ECMO 102: Identifying Recirculation When Rounding on VV-ECMO by Fraser Mackay

  • Recirculation is a phenomenon unique to VV-ECMO patients and can explain worsening hypoxia.
  • Recirculation occurs when pump flow is diverted away from the RA/ TV and directly into the drainage cannula.
  • Practically speaking, an increasing SpreO2 combined with a decreasing SaO2 may indicate clinically relevant recirculation is ongoing. A SpreO2 ≥ SaO2 cannot be explained without a recirculation event. 
  • Recirculation may be positional, or may be related to changing pressures in the chest or abdomen.
  • Consider cannula-related and non-cannula causes for recirculation.
  • Recirculation forms one of the logistical ceilings for escalating flow. When recirculation occurs, further increases in circuit flow likely will not improve oxygen delivery

Showdown of Inotropes by Nishika Patel 

  • The European and American cardiogenic shock guidelines do not recommend a specific inotrope for the treatment of cardiogenic shock.
  • The DOREMI trial showed that there was no statistically significant difference between milrinone and dobutamine for the primary outcome of in-hospital death from any cause, resuscitated cardiac arrest, receipt of a cardiac transplant or mechanical circulatory support, nonfatal myocardial infarction, transient ischemic attack, stroke, or the initiation of renal replacement therapy.
  • In patients previously on carvedilol, dobutamine may be less effective than milrinone. This is also true for patients previously on metoprolol, although to a lesser extent. Overall, in these patients receiving prior beta-blockade, milrinone may result in a better hemodynamic response than dobutamine.

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