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Melina Alexander
St. Vincent's Emergency Medicine Resident, PGY-1
COMING UP THIS WEEK:
Our new nurse education content will be starting TOMORROW! Stay tuned for BEDSIDE WARRIORS!
For some spaced repetition, here’s a review of this week’s content:
Mega Dose – ROC by Terren Trot
- Data definitively supports a dose of 1.2mg/kg rocuronium in RSI
- There is some limited data to support higher doses, as high as 2.0mg/kg without significant side effects.
Quiet the Storm: Propofol for Ventricular Arrhythmias by Mohamed Hagahmed
- Ventricular storm is a condition that is associated with a significant catecholamine surge.
- In patients with VS, prompt identification of reversible causes and avoiding interventions that increase sympathetic output will improve mortality.
- Propofol can be a helpful adjunct in mitigating the sympathetic overdrive in patients with VS.
- A single propofol bolus (1 mg/kg) may be a safe and alternative therapy for VS. If unsuccessful; then the patient is sedated and ready for cardioversion.
VV-ECMO 101: Going “On Pump” for Acute Pulmonary Failure by Fraser Mackay
- VV-ECMO is a branch of ECLS that provides supplementary gas exchange for reversible pulmonary disease.
- VV-ECMO is not for the chronically ill or for those with multi-organ failure. It’s best used early in otherwise healthy patients with devastating single-organ failure.
- With judicious patient selection and multidisciplinary support, it represents an important salvage modality for those suffering from pulmonary failure.
Precedex, I Love You But You’re Bringing Me Down by Nishika PatelÂ
- The incidence of hypotension and bradycardia with dexmedetomidine is 24-56% and 5-42% respectively.
- Based on one retrospective study, the predictors of dexmedetomidine-associated hypotension include increased age, higher APACHE II scores, history of CAD, and a lower baseline MAP.
- To reduce the risk of hemodynamic instability, avoid bolusing, particularly in cardiac patients; if you do still choose to bolus, reduce the dose or increase the time over which the bolus is delivered to 20 minutes. Lastly, titrate the infusion no more frequently than every 30 minutes to reduce the risk of hypotension.
Optimal PEEP by Seon Adams
- Finding the correct setting for PEEP can lead to improved outcomes in ventilated patients.Â
- Driving pressures is a simplistic way of finding optimal PEEP.Â
- Check out this post on driving pressures and PEEP titration by Dr. Matt Suiba.
Ultrasound- Guided Subclavian Central Lines: Part 2 by Harman Gill and Matthew TylerÂ
- Check out the video for a more in-depth analysis of ultrasound-guided subclavian central lines
- Long axis vs short axis views have their pros and cons; find the one that works best for you.
- Consider using the PART technique
- The micropuncture needle may not be the best tool for this procedure.
- Preparation is key; position the patient in the best way for first pass success
A Ride Through Right Ventricular Assessment: Part 3 by Segun Olusanya and Korbin Haycock
- Look for septal shift and the relative size of the LV and RV. Septal shift may be in diastole, systole or both, indicating volume or pressure overload. Â
- In addition to TAPSE and S’, look at the RV free wall and fractional area of change.
- The relative size of the atria, atrial septal shift, and the IVC also provide clues to right ventricular filling pressures and performance.
