Week in Review: 11/15/20

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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:

Should you Pre-Ox with a BVM? by Steve Haywood and Caleb Harrell

  • You can use a BVM for pre-oxygenation without squeezing the bag with the following caveats. 

    1. The BVM must be attached to high flow oxygen (>15LPM) and have a reservoir attached. 
    2. The patient must have adequate respiratory effort. If not, you should be squeezing the bag.
    3. You must hold a tight seal against the patient’s face. This tight seal is necessary to open the valve from the bag to the mask. 
    4. You must use a PEEP valve. Depending on the brand of BVM, the patient may be able to entrain room air through the exhalation valve. A PEEP valve assures no air will come in through the exhalation port.

Rh Status and the Pregnant Trauma Patient by Ashika Jain, Shona Jain, Kavita Jain

  • Give rhogam to any/all Rh negative pregnant trauma patients
  • Updating tetanus is safe in pregnant patients – should be administered at 28 weeks in every pregnancy
  • The KB test can be utilized in all pregnant trauma patients

Management of Severe TBI: Decompressive Craniectomy by Shyam Murali

  • Cerebral edema can cause brain tissue displacement and hernia, as well as regional ischemia. DC can relieve ICP and prevent herniation.
  • The DECRA and RESCUEicp trials currently provide the best evidence about DC but the effect of DC on favorable outcomes is still uncertain.
  • The latest guidelines for DC in severe TBI recommend secondary DC (via a large frontotemporoparietal DC) for late refractory ICP elevation.

Contrast in Lung Ultrasound by Siri Chamarti

  • Contrast Enhanced Ultrasound (CEUS) should be considered in the setting of a high D-dimer given associated mortality of COVID19
  • Detection on peripheral subpleural consolidation could be a sign of peripheral infarction further evaluated with CEUS.

The Vitals: Lactic Acidosis by Obiajulu Anozie

  • Critical lab findings are the result of significant, pathophysiological perturbations that demand an equally physiological approach to properly address.

What’s up With SUP? Update on the use of Stress Ulcer Prophylaxis by Lauren Igneri

  • SUP should be reserved for those at high and highest risk for developing clinically important and overt upper gastrointestinal bleeding 
    • PPIs may reduce the risk of clinically important and overt GI bleeding to a greater extent than H2RAs
    • SUP likely increases the risk of developing pneumonia
  • Local prescribing practices and order sets should be updated to risk stratify patients in order to minimize the risk to benefit ratio of using SUP


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