Week in Review: 12/13/20

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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:

Reversible Causes of Low ETCO2 in CPR by Steve Haywood

  • If the EtCO2 is low early in cardiac arrest, look for a reversible cause.
  • First, assure proper chest compressions and ventilations.
  • Next look for reversible causes of right ventricle obstruction.
  • Finally, consider an equipment malfunction.
  • If no reversible cause of low EtCO2 is discovered, the patient’s likelihood of survival is low, especially after 20 minutes of resuscitation.

A Toxic Viral Mimic by Mohamed Hagahmed

  • Take a second to consider other differential diagnoses. Maybe it’s not COVID. Avoid anchoring bias.
  • The most crucial step in making the diagnosis of staphylococcal TSS is to simply consider the diagnosis.
  • Think beyond tampons! There are many causes of staphylococcal TSS. Consider the possibility of not finding a cause.
  • Be aggressive with fluid management and go broad with antibiotics.

Upside Down World: A Foray Into Volume De-Responsiveness by Sharad Patel

  • Patients with sepsis require fluids but large volumes can be harmful. Fluid balance, weight, lung ultrasound, and IVC are some traditional methods to identify volume intolerant patients.
  • A patient who is volume intolerant may warrant volume removal.
  • Methods for volume responsiveness can be used to determine volume de-responsiveness (A physiologic hypothesis at this point that warrants further study).

Battle of the Blockers: Time for a Peace Treaty by Rachel Rafeq

  • Neuromuscular agents provide no sedation or analgesia and therefore adequate sedation and analgesia should be administered before and after administration 
  • At higher doses of 1-2 mg/kg, rocuronium has a similar onset of action as succinylcholine (60 seconds); however rocuronium will last for 30-60 minutes compared to succinylcholine, which lasts 5-15 minutes. 
  • Consider appropriate induction agents that have durations similar to the neuromuscular agent that is being utilized
  • Succinylcholine may be an ideal agent compared to rocuronium for patients who are being intubated post seizure event
  • Rocuronium may be an ideal agent compared to succinylcholine in patients where risk of hyperkalemia, malignant hyperthermia, increased intraocular and intracranial pressure exist. 
  • Rocuronium may also be an ideal agent in patients whose history is unknown or whose lab work is unavailable.

CPT Part 1: Percussion and Postural Drainage vs. High-Frequency Chest Wall Oscillation by Seon Adams

  • Chest physical therapy (CPT or Chest PT) is an airway clearance technique (ACT) to drain the lungs and may include percussion (clapping), vibration, deep breathing, and huffing or coughing.
  • Postural drainage involves the use of gravity and mechanical energy to help mobilize secretions.
  • High-frequency Chest Wall oscillation creates microscopic “coughs” in the patient’s alveoli releasing mucus from blocked airways and moving them into larger airways to be coughed out or suctioned.

The Vitals: Our ICU Patients Need a Fast Hug Every Day by Shyam Murali

  • The FAST HUG mnemonic is a great way to remember key aspects of the general care of our ICU patients.
  • Use any one of the many variations to help you when you round on your patients!

What is S’? by Segun Olusanya

  • Lateral tricuspid annulus peak systolic velocity is abbreviated to S’ (Pronounced “S Prime”)
  • It’s a tissue doppler derived measure of RV systolic function
  • You measure it using an RV focused view and placing a tissue doppler gate over the lateral tricuspid annulus
  • Normal value is 10cm/s. Less than that is considered impaired
  • It is angle-dependent (less so than TAPSE) and doesn’t always correlate well with overall RV function


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