Week in Review: 2/28/21

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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:

Can We Really Obtain Optimal PEEP with a Balloon by Komal Parikh

  • An esophageal balloon catheter is another tool in the toolkit to examine the optimal PEEP for obese critically ill patients and patients with ARDS. 
  • It does come with its own caveats, but if the operator is skilled in inserting the catheter and interpreting the data, it can be a great instrument to assess for the ideal PEEP in these specific patient populations.

Becoming The Ben Franklin of Ventricular Storm by Jeff Pepin

  • Patients in cardiac arrest who present in ventricular storm can be challenging to manage.
  • Assemble your team and assign roles before the patient arrives in your ED. Ensure the availability of the equipment and medications you need to manage VS
  • Avoid exacerbating the catecholaminergic surge in these patients. This may require you to deviate from the standard ACLS algorithms
  • Many patients in VS have underlying ischemic heart disease. Involve your interventional cardiologists early.

Alphabet Soup: Monitoring of Anticoagulation on ECMO by Colin McCloskey

  • There are many options for monitoring heparin anticoagulation while on ECMO
  • There is no perfect test. ACT is insensitive, aPTT is affected by acute phase reactants and factor deficiency, Anti-Xa is expensive, and TEG/ROTEM has limited evidence.
  • The best test is the one you can use at your shop. My approach is to target Anti-Xa levels and evaluate the patient clinically for bleeding or ECMO membrane clotting. TEG is a useful adjunct.

The Hybrid Model: The Best of Both Worlds? by Zack Repanshek

  • The hybrid model may be the best possible solution to the very modern problem of social distancing. When done with adequate forethought and setup, it can provide the engagement and sense of community we sorely miss while still creating an opportunity to participate from afar.

Critical Care in a Submarine by Mike Tom

  • Given hands on access to the critically ill patient, multiplace hyperbaric chambers are preferred and arguably required for the critically ill patient.  
  • Most multiplace hyperbaric chambers are staffed by EM or anesthesia trained physicians and can accommodate patients on the ventilator, with vasopressor requirements, and with invasive blood pressure monitoring.  
  • Risks and benefits need to be carefully considered in those requiring extreme levels of ventilatory or vasopressor support as a code in a chamber can be very difficult to manage.

The Case for AVAPS by Stephen Biehl

  • AVAPS uses a Min P and Max P instead of set IPAP to deliver a set VT
  • AVAPS improves dyssynchrony and patient compliance, leading to improved patient outcomes
  • AVAPS is not just for chronic conditions anymore and has shown to be highly beneficial in acute COPD and OSA.

The Vitals: IV Fluids – Compositions and Choices by Jon Pickos

  • Each patient’s comorbidities and presentation should be taken into consideration when selecting an IV fluid for resuscitation.
  • Fluid choice can be detrimental to a patient’s care and recovery, especially with larger volume resuscitation (such as normal saline in already acidotic states like DKA and sepsis), thus, the fluid selected can be physiologically supportive or an obstacle to overcome.
  • Mounting evidence supports balanced IV fluid resuscitation is the ideal approach for critically ill patients.

The Rad Review: Episode 9 by Rupal Jain

  • Dot sign vs Spot sign radiographic abnormalities 
  • Dot sign – seen on Non-Contrast CT of ischemic strokes 
  • Spot sign – seen on CT Angiography of hemorrhagic stroke 
  • Both signs are associated with increased mortality 


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