Week In Review: 6/13/21

Reading Time: 4 minutes

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

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

Whether in the ED or the ICU, providers sometimes rely on heuristics, or mental shortcuts, to make decisions based on their prior experiences, recognized patterns, and old habits.
The field of behavioral economics, founded by the psychologist Amos Tversky and Daniel Kahneman, explores human decision making without the assumption that humans are rational actors.
System 1 represents fast-twitch, unconscious intuitive reasoning while System 2 is conscious, analytical, and methodical. System 1 is prone to cognitive biases, while System 2 seeks to prevent these cognitive errors.
The tendencies to err occur for various reasons, including heuristics, the limited cognitive bandwidth of the brain, environmental and social influences, our emotional and moral motivations, and challenges in remembering or recalling information and memories.
To prevent these errors in cognition, we must know what they are.

While no study has shown a clear cut benefit between PSV and T-piece trials, it has been shown that the length of time of an SBT should not be longer than 2 hours, and should ideally be at least 30 minutes. The shorter the time of SBT, the better tolerated the extubation will be.
As with all things in medicine, each patient should be thought of as a unique case and these studies should be used as guidelines, but not hard evidence and rules for how an SBT should be done. Remember the etiology of the respiratory failure of your patient, his or her current respiratory and cardiac situation, along with all the points we discussed in the last article before making an educated and thoughtful decision on which type of SBT you will do. Remember that the landing (and how the landing is done) is just as important as the take off when it comes to extubation!

Early recognition is critical with bedside clinical assessment followed by laboratory findings. If you suspect something, say something to your team.
Ensure adequate IV access and maintain aseptic technique
Early antibiotic administration (within 1 hour) is the most vital; try and obtain cultures before antibiotic administration, DO NOT DELAY if unable to obtain the cultures
Balanced IV crystalloid for initial fluid resuscitation to goal MAP > 65 mmHg
If unable to maintain MAP with initial IV fluid resuscitation, consider early initiation of vasopressors
If vasopressor requirements continue to increase, initiate hydrocortisone

Nitrates have long been used for treatment of ischemic chest pain in acute myocardial infarction but contraindicated in cases of hypotension, bradycardia, 5’ phosphodiesterase inhibitor use, and right ventricular infarction.
Research from the last several decades has shown modest mortality benefit, at best, but NTG does help to alleviate chest pain which does have clinical benefit.
More recent data is less clear as to whether the risk of profound hypotension with nitrate use in right-sided MI is as great as we think.
While current ACC/AHA recommendations remain to avoid use in right-ventricular MI, fluid status assessment, pressure support and/or control, and adequate analgesia all remain key elements of patient management regardless of site of infarct

The pulsatility index of LVADs represents the magnitude of flow pulse through the LVAD. It is a marker of circulating blood volume and native LV contractility. A fall in PI should prompt evaluation of volume status and native LV function.

So the next time you get ready to deliver some feedback on your next shift, think of how you can BOOST your feedback to make it more effective.

CRAO is the equivalent of a stroke of the eye. Stroke alert activation is therefore appropriate at presentation to expedite ophthalmology and neurology evaluations as well as neuroimaging.
While rare, CRAOs typically have poor outcomes, with 80% of patients without the cilioretinal arterial variant having long term visual acuity of finger counting or less.
Risk factors are similar to those of other strokes and include atherosclerosis and advanced age among other general cardiovascular risk factors.
Treatment options are limited. tPA and HBOT can both be considered as treatment options for CRAO. Further studies will be useful for each independently as well as for both in combination as treatments for CRAO

The use of a combined SBT and SAT weaning protocol results in better outcomes.
The Cochrane systematic review showed that protocols led to shorter total mechanical ventilation days with fewer side effects, shorter duration of weaning, and ICU length of stay.
Weaning predictors are parameters that are intended to help clinicians predict whether weaning attempts will be successful or not and are not absolute.

The Vitals: Barotrauma by Obiajulu Anozie

Barotrauma occurs when transpulmonary pressures exceed a threshold
Transpulmonary pressure = Plateau Pressure – Pleural Pressure
Barotrauma as a form of VILI that can occur when the lungs are exposed to excessive transpulmonary pressures. To minimize this risk, it is always imperative to employ lung protective ventilation strategies

Use the abdominal probe to identify the ideal location to perform a paracentesis for ascitic fluid drainage
Use the superficial probe to ensure that there aren’t any abdominal wall blood vessels in the path of the proposed procedure sit