Week in Review: 10/25/20

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Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father

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

ETCO2 & Dead-Space by Steve Haywood

  • Dead space is gas in the pulmonary system that does not participate in gas exchange.
  • We have normal anatomic dead space made up of the trachea and bronchial tree.
  • Patients also have physiologic dead space composed of alveoli that are not participating in gas exchange.
  • When the fraction of dead space exceeds 0.3, we must have a concern that our patient’s physiologic dead space is increasing.

Can we Just Stay and Play a While? by Zaf Qasim

  • Transporting a patient without achieving ROSC means that there will be interruptions in chest compressions
  • This recent study showed that patients who received on-scene resuscitation until ROSC had improved survival to hospital discharge and survival with favorable neurological outcome

Off-Label Drug use in Pediatrics by Samantha Dallefeld

    • There are some very important considerations when giving medications to pediatric ICU patients for off-label uses
    • Remember to consider the differences in metabolic capacity, renal function, distribution, skin development, and GI function

Let’s Talk Tamponade (Physiology) by Gurkeerat Singh

  • Always use EKG leads to identify systole and diastole. 
  • Tamponade is a clinical diagnosis that depends on hemodynamics at a particular point in time. 
  • Severe pulmonary hypertension will protect from RV and RA collapse leading to atypical sings for tamponade. Drainage can lead to death. 
  • Significant pleural effusions can lead to tamponade which can reverse with effusion drainage.

The Vitals: When to Pull the Tube by Sunil Ramaswamy

  • Remember to use your eyes, ears, and communications skills when deciding if a patient is ready for extubation
  • The Rapid Shallow Breathing Index (RSBI) can help predict if extubation is likely to fail

The Acutely Agitated Adult ED Patient by Rachel Rafeq

  • There are many options for treating the acutely agitated adult patient
  • Use the infographic in this post to learn about how to manage them

Central Line Tips & Tricks: Part 3 by Harman Gill and Shyam Murali

  • Get the kit and ergonomics essentials from the previous videos (Part 1 and Part 2)!
  • One hand technique vs having a helping hand to drape the US probe; this is a big area of procedural contamination.
  • There are different types of introducer needles – check your kit or watch the video
  • Sharp angle for introducer needle entry and then drop the angle when you advance wire
  • Confirm wire in two planes with US
  • Avoid skin tags
  • Once you feel the ‘give’ with the dilator, make sure the wire advances and retracts with no resistance
  • Angle of dilation should mimic the angle of introducer needle entry…not sure what this means…watch the video!


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