Week In Review: 5/9/21

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Picture of 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:

The Landing is Just as Important as the Take Off: A Closer Look at Assessing a Patient for Extubation by Komal Parikh

  • It is very difficult to perform all of these points when assessing every single patient for extubation, but note that each patient is different and there is not one cookie-cutter way to extubate a patient. The fortunate part about being in an intensive care unit is that there are always several different modalities and tools that can be kept in your armatematerium and utilized accordingly. Happy extubating!

How to Handle the Hand OffL Working with EMS to Ensure Good Transitions of Care by Seth Kelly 

  • It is important to have a formal handoff process between prehospital providers and in-hospital teams to communicate key elements of patient condition and any interventions/treatments rendered prior to arrival at the hospital.
  • Standardized tools, like DMIST, ensure a consistent format for the EMS handoff to reduce errors or opportunities for lost information.
  • The receiving team should ensure that an EMS timeout is performed to allow for the EMS handoff report to be delivered in a distraction-free setting with opportunity for clarifying questions from the receiving team.
  • The verbal EMS handoff report should be followed by a written or electronic report to allow for continuity of care and should be added to the patient’s medical record to be available to all members of the care team

Surviving Sepsis: Pediatric Style by Samantha Dallefeld

  • Let’s get the case polished off:

  • The child is determined to be in septic shock. 40ml/kg of lactated ringers is administered in 20ml/kg aliquots. The first bolus of fluid briefly improved the blood pressure, but it subsequently fell and the 2nd aliquot was not beneficial. While fluids were being administered, zosyn was initiated and labs were sent including a comprehensive metabolic panel, complete blood count, blood gas, coagulation studies, type and screen, and blood culture. Central venous access was established and epinephrine was started at 0.05mcg/kg/min and titrated to an appropriate blood pressure for age. The child was then transferred to the PICU for continued management.

  • Check out: the Surviving Sepsis Campaign’s Pediatric Sepsis Guidelines for more about these modern recommendations on how to treat sepsis – pediatric style!

Stroke Alert to the PACU by Mike Tom

  • In a peri-procedural, stroke-like patient, keep cerebral arterial gas embolism on the differential.
  • While intravascular air on neuroimaging is confirmatory, this is not always present.  CAGE is a clinical diagnosis with the timing of symptoms in association with a procedure (or diving) being key.
  • Physical bubble resorption as well as blunting of ischemia-reperfusion injury are how HBOT can be helpful in CAGE.
  • If feasible, treatment for CAGE is immediate HBOT

The COVID-19 Diffusion Dilemma by Stephen Biehl

  • Decrease in DLCO can be seen in patients following COVID-19, with varying results based on severity of disease and time performed.
  • A decrease in DLCO can be found in Pulmonary Hypertension and Pulmonary Fibrosis, which may possibly be caused by COVID-19 infections.
  • Pulmonary Rehab programs may be vital to improve the quality of life in patients who have had COVID-19.

The Vitals: The Fresh Trach of Bel-Air by Sunil Ramaswamy

  • Tracheostomy emergencies can be extremely scary events. Start off by taking a deep breath before you jump into caring for your patient.
  • Take a look at your patient, the vital signs monitor, and the ventilator, looking for signs of obstruction, bleeding, or a false tract.
  • Call your backup early and be prepared to handle catastrophic events.

The ABCT’s of CT Imaging (Part 1) by Rupal Jain

  • Pearl #1: CT relies on x-ray beams and various tissue impedance of these x-ray beams to create black-white images. Tissues with high attenuation (or high impedance of x-ray beams) are by convention WHITE, i.e. Bones. Tissues with low attenuation (or low impedance of x-ray beams) are by convention BLACK, i.e. Air. 

  • Pearl #2:  The Hounsfield unit of blood is approximately 50.

  • Pearl #3: The timing of CT scan in relation to the injection of contrast media is the basis for various phases of CT scans. Depending on your clinical question, the radiologist will protocol the CT scan to look at the pathology of interest in the non-contrast CT or CT timed for arterial, venous or delayed phase. The CT technologist will then perform the CT scan after specific time-delays after injection of contrast, basically timing the contrast to either be in arterial or venous circulation or excreted in ureters.

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