Week in Review: 10/4/20

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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:

Equation of Motion: Part 1 by Aman Thind

  • While assessing a respiratory pathology causing high ventilatory load, it is important to analyze if that excess load is resistive or elastic, and if the bulk of the ventilatory work is performed by the patient or the ventilator.

Get in the Zone: Penetrating Neck Trauma Part 2 by Ashika Jain

  • With penetrating neck trauma, determine in what zone your patient is injured
  • Then determine if your patient is stable or unstable
  • Take control of the airway if needed
  • Determine what kind of imaging is needed based on the location of the injury and which structures could potentially be damaged

Surviving Sepsis: Pediatric Style by Samantha Dallefeld

  • For a child in septic shock the following must be done quickly:
    1. Obtain IV/IO access.
    2. Collect blood culture – if difficult to obtain, move quickly to step 3.
    3. Start empiric broad-spectrum antibiotics (table 1).
    4. Measure lactate.
    5. Administer fluid boluses 10-20ml/kg IF shock present and the patient doesn’t otherwise have evidence of fluid. *Repeat this step and consider additional boluses of 10-20ml/kg until shock resolves or signs of fluid overload develop.
    6. Start vasoactive medications if shock persists after step 5.

ResusX19: Pearls from Day 2 by Shyam Murali

  • Catch up on day 2 lectures from ResusX19 as we get closer to #ResusX20!

Oh My Gad! What You Need to Know About Gadolinium by Rupal Jain

  • Pearl #1: Not all MR Angiography studies utilize contrast. 
  • Pearl #2: Gadolinium-based contrast agents should be avoided in pregnancy. Due to risk of nephrogenic systemic fibrosis, should also be avoided in those with kidney disease.
  • Pearl #3: Gadolinium may be deposited in multiple organs after contrast-enhanced MR study, however currently there is no evidence that this his harmful

The Vitals: Elevated Troponins by Michael Javid

  • Think of troponin as a lab result that can elevate from multiple causes, not just myocardial infarction
  • It’s helpful to keep a list of reasons for elevated troponin

Central Line Tips & Tricks Part 2 by Harman Gill and Shyam Murali

  • Familiarize yourself with the important pieces of equipment in your kit and make sure to grab necessary components that are not in your kit
  • Set out your kit contents in order of when you need them in the procedure
  • The blue and red scalpel has a stopper that will prevent you from cutting too deep but use your ultrasound to have guided confidence about your vessel depth
  • The micropuncture needle can get you out of a corner, so familiarize yourself with how to use it.

Albumin for Volume Expansion in Patients with Cirrhosis and AKI by Eduardo Argaiz

  • Patients with Cirrhosis and AKI present heterogeneously, not every patient is volume depleted while some are volume overloaded
  • A good physical examination augmented by POCUS can reveal volume overload in this population
  • Empiric IV albumin infusion for volume overloaded patients makes no physiological sense and might lead to adverse consequences
  • Appreciating that volume expansive treatment should be tailored to underlying physiology and hemodynamic status will be a long battle with constant pushback from some (for example, this was shared with me by Dr Gomez Johnson: https://twitter.com/vikouerMD/status/1308199931396722689?s=20 )
  • But one must remain vocal in order to achieve change!
  • In this regard the effort from @NephroP @NephroGuy and @medpedshosp should be commended (read their letter to the editor here: https://www.bmj.com/content/370/bmj.m2687/rapid-responses

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