Week In Review: 3/28/21

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Melina Alexander
Melina Alexander
St. Vincent's Emergency Medicine Resident, PGY-1

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

CriticalCares: Health Disparities in the ICU – Here’s What You Need to Know by Bassam Zahid

  • In the entire continuum of acute critical illness, health disparities have been observed from individual susceptibility to clinical presentation to medical treatment to final outcomes.
  • Factors contributing to healthcare disparities include race, gender, and sexual orientation, access to and delivery of healthcare, patient education and finances, and social and cultural differences. These disparities have been noted for nearly every major disease.
  • In order to work towards healthcare justice, we must educate and empower our patients, make healthcare disparities discussions a part of rounds, conduct research and monitor progress on healthcare inequities, hire diverse staff and providers, and make our voices heard to administrators and politicians.

All Flow No O’s: High Flow Nasal Room Air by Steve Haywood and Caleb Harell

  • The study cited below found that High Flow Nasal Room Air did provide relief to normoxemic patients in respiratory distress. 
  • Patients felt better with High Flow Nasal Room Air than they did with low flow oxygen. 
  • Normoxemic patients do not need supplemental oxygen, but may feel better with High Flow Nasal Room Air

Pause for the Pause by Fraser Mackay

  • Make it clear that the code is not over: “Hey everyone, before you leave I would like to say something.”
  • Say the patient’s name as well as something else. Don’t be afraid to ask or use the wrist band. If I did not know the patient before the code, I usually say: “This was John Smith. I did not know him, but he was a man in the hospital and was trying his best to get well again.”
  • Take the moment of silence. Less than a minute is needed. 
  • After the moment of silence, thank the team. “I know this was hard, but I know everyone did their best for John. Thank you for all that you did.”

Fomepizole: Not Just for Toxic Alcohol Toxicity by Ruben Santiago

  • Acetaminophen overdose is a common presentation to the emergency department
  • NAC is the only FDA approved agent for APAP overdose and works primarily by providing GSH stores to detoxify NAPQI
  • There are instances when, despite therapy with NAC, hepatotoxicity still occurs
  • Fomepizole inhibits NAPQI through CYP2E1 inhibition and prevents further hepatotoxicity through JNK inhibition
  • For massive APAP overdoses, fomepizole may be considered as an adjunct to NAC to combat hepatotoxicity 
  • Always consult your poison control center at 1-800-222-1222 when these patients present

To Inflate or Deflate: Tracheostomy Tube Cuff by Danelle Howard 

  • When the cuff is deflated, some airflow is reestablished through the upper airway resulting in vibration of the vocal cords
  • Cuff deflation leads to a more natural physiology in turn speeding up rehabilitation process
  • Cuff inflation can lead to silent aspiration

Subclavian Deep Dive by Harman Gill and Matt Tyler 

  • Anatomy: Placed at the junction of the medial and middle third of the clavicle 
  • Indications: Central venous access, infusion of vasoactive/caustic infusions, hemodynamic monitoring (namely CVP)
  • Risks: Bleeding, pneumothorax, and infection (although subclavian lines are considered to be least infection-prone) 
  • Procedure: Watch the video!
  • Anatomy: Placed anywhere the axillary/subclavian vein is visualized with ultrasound
  • Indications: Same as above 
  • Risks: Same as above but less likely to cause pneumothorax as pleural line is under constant and direct visualization 
  • Procedure specifics: Watch the video! 
  • Literature supports the merits of this version of subclavian central line placement over the traditional, landmark based approach 
  • Can be technically challenging
  • Need to have strict control and visualization of the needle tip at all times 
  • Tips for troubleshooting…coming up next time


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