Week In Review: 4/18/21

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

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

From the perspective of a single alveolus, it doesn’t matter whether a particular volume of gas is delivered via PPV, NPV, or a combination of the two. The eventual stress/strain in either case would be identical. There is nothing inherently injurious about PPV.
When the whole lung is taken into account, important differences between NPV and PPV (at a given tidal volume) arise, especially in patients with ARDS.
In general, vigorous respiratory efforts have some harmful effects while milder degrees of effort may have some beneficial effects compared to passive PPV.
The idea that high-volume spontaneous breathing may worsen lung injury in severe ARDS is backed by solid physiological reasoning and common sense. In such a scenario, ‘taking control’ of the ventilation with low-volume passive PPV would result in safer ventilation.
Broadly speaking, our relative tolerance for vigorous ‘high-volume’ spontaneous breathing should reduce as the severity of ARDS increases.

The prehospital evaluation of patients with rib fractures, like any trauma patient, emphasizes scene safety, airway, breathing, and circulation
Paramedics should have a high index of suspicion for underlying devastating injuries
Manual stabilization of a flail segment, as well as IV analgesia, are important prehospital interventions
Rapid stabilization and transfer to a trauma center contribute to better outcomes in patients with rib fractures
Next in Part 2: We will discuss the challenges of identifying and managing tension pneumothorax in the prehospital setting as well as EMS pain management.

LVAD Infections 101 by Colin McCloskey

LVAD driveline infections are common (10-20% incidence per year) and are diagnosed clinically
Treatment ranges from antibiotic therapy to LVAD exchange
An ounce of prevention is worth a pound of cure: Driveline care in-hospital and at home is paramount to preventing this morbid complication

As with any procedure, good preparation helps lessen the likelihood of complications. Similarly, these preparation steps allow the feedback to proceed with the lowest likelihood for complications. Therefore, consider these preparation steps before your next shift when you may have to provide feedback.

The rate of true IgE-mediated reactions to beta-lactams is 0.001%- 0.0005%.
The most common beta-lactam reaction is a maculopapular rash which is not a true IgE mediated reaction.
Documented beta-lactam allergies should be reviewed to determine if a true allergy exists or if the allergy is a mislabel. Mislabeled allergies should be removed from the chart to prevent patients from being precluded from future beta-lactam therapy.
Cross-reactivity between beta-lactams is dependent on the R1 side chain of the chemical structure.
1. Identical R1 side chain: true cross-reactivity is likely and an alternative agent may be considered.
2. Similar R1 side chain: use clinical judgment to determine if the reaction should be challenged.
3. Different R1 side chain:, cross-reactivity is unlikely and beta-lactam use may be appropriate.

RT’s Zap Vap by Seon Adams

Routine oral care plays a key role in preventing VAP
A MINI-BAL can be as effective as a Bronchoscopic BAL
VAP puts a strain on healthcare and can be prevented with proper medical prevention, including respiratory care

(Ab)normal saline and the excessive chloride content prevent the body’s natural buffer system, H+ and HCO3-, from functioning optimally.
Excess chloride causes bicarbonate to shift intracellularly to theoretically maintain electroneutrality which ultimately inhibits bicarbonates ability to buffer acidotic states (i.e. sepsis and other shock physiologies).
Critically ill patients require a fine tuned approach to their resuscitation including consideration of the underlying physiology (such as severe acidosis from sepsis) and the impact of fluid resuscitation (and its relation to the underlying physiology).
Mounting evidence suggests that (ab)normal saline is not the optimal fluid for resuscitation of our critically ill patients.

Skiing down the cardiomediastinal silhouette on a chest x-ray can provide *mounds* of information
The third mogul is NEVER normal (90% of the time it indicates rheumatic heart disease, but can also be due to left atrial enlargement from cardiac aneurysm, coronary artery aneurysm, pericardial cyst/defect, tumor)