Week In Review: 4/11/21

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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:

Ground Control to Major Tom: What is the Role of Helmet NIV in ARDS? by Matt Siuba 

  • High flow nasal cannula has established itself as the standard of care in de novo hypoxemic respiratory failure since the FLORALI trial. It provides some degree of dead space washout, theoretically decreasing minute ventilation requirements and potential lung stress and strain. A nominal amount of PEEP is provided as well. In HENIVOT, however, the intubation rate was higher in the HFNC group compared to helmet NIV. Interestingly, there was more barotrauma in the HFNC group, though it did not achieve statistical significance. This may be due to excessively negative pleural pressures with vigorous spontaneous efforts.

    When possible, safely avoiding invasive ventilation provides a huge benefit to both patients and health systems. In expert hands, helmet NIV appears to reduce the intubation rate of patients with moderate to severe ARDS. Further studies are needed to define the safety and effectiveness of helmet NIV with pragmatic use.

Neurogenic Shock by Mohamed Hagahmed

  • Neurogenic Shock is a diagnosis of exclusion. Consider it in your trauma patient with unexplained hypotension and bradycardia after ruling out hemorrhage or other internal injuries (Tension Pneumothorax, Pericardial Tamponade, etc.)
  • In elderly patients, factors such as medications (Beta Blockers) or age-related neurocognitive deficits can mask the severity of their symptoms. Maintain a low threshold for considering spinal injuries in these patients.

So You Ordered a ROTEM on Your ICU Patient, Now What? (Part 2 of 2) by Fraser Mackay

  • ROTEM is a viscoelastic assay that may be a helpful adjunct to caring for patients in specific circumstances during their resuscitation or ICU course
  • Consider using ROTEM in the following scenarios:
    • Large scale blood resuscitation (MTP activation)
    • Unexplained bleeding episodes
    • Pre, peri, and post-operative and courses for liver and cardiothoracic surgery cases
  • It is essentially the only lab test that objectively demonstrates fibrinolysis. In cases of suspected DIC or fibrinolytic crisis, it may help clinch the diagnosis.
  • Develop a familiarity with waveform shapes and parameter metrics and a systematic approach to how you may want to transfuse (and your transfusion targets).

Is the Juice Worth the Squeeze? by Lauren Igneri

  • Historically, observational and retrospective studies demonstrated a benefit with the initiation of midodrine to wean IV vasopressor therapy.
  • Recent literature including the prospective, randomized controlled MIDAS study and a large meta-analysis did not find that the addition of midodrine resulted in significant differences in time to IV vasopressor discontinuation, ICU LOS, hospital LOS, or mortality.
  • Midodrine initiated for vasopressor weaning is commonly inadvertently continued at ICU or hospital discharge. In many cases, antihypertensive therapy is initiated to combat BP. elevations from midodrine.
  • If midodrine is used for vasopressor weaning, it is important to have plans in place for tapering and discontinuation at transitions of care.

The Air in There – Lung Volumes by Stephen Biehl

  • Each of the three options for measuring lung volumes are not necessarily better than another when compared in various studies
  • Further work to perfect the values found in lung volume studies will help determine the ideal method for evaluating patients
  • Proper technique and guidance play a vital role in proper diagnosis

The Vitals: Sleep Series Part 1 by Bassam Zahid

  • Sleep is a state of altered consciousness, characterized by cognitive and sensory disengagement from external reality that naturally occurs and is periodic, linked to the day-night cycle. There are reduced interactions with the surroundings, decreased muscle activity, and a diminished ability to react to stimuli up to a certain individual threshold when one can be aroused.
  • There are many theories on why we need sleep. The five most likely are the evolutionary/inactivity theory, the energy conservation theory, the repair and restore theory, the brain plasticity theory, and the brain clean up theory. The true reason is likely to be a combination of these.
  • Sleep is essential for cognitive, physical, and emotional performance. Both acute and long-term sleep deprivation is deleterious to our health. Ensuring proper provider and patient sleep hygiene is paramount

Suspect PE? Look for DVT? by Manoj Wickramasinghe

  • DVT ultrasound can be very useful in patients with suspected PE. 
  • It can help guide difficult clinical decisions such as thrombolysis, preclude the need for more advanced testing, and allow for more timely initiation of therapeutics. 
  • So, after you’ve done that echo at the bedside, make sure you have a look at the lower limbs too!
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