Week In Review: 6/6/21

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

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

ECG 101 by Alyx Presler

  • Know the definition of sinus rhythms
  • Follow the same algorithm every time you assess an ECG. Make it habitual!
  • Walk yourself through as many ECGs as possible, practice makes improvement

Assessing Inspiratory Efforts in Intubated Patients by Aman Thind

  • In assisted mechanical ventilation, the ventilatory load is shared by Pvent (positive airway pressure applied by the ventilator) and Pmus (inspiratory muscular pressure of the patient).
  • The concept of ‘diaphragm-protective ventilation’ strives to provide adequate Pvent, so that both over-assistance and under-assistance are prevented.
  • Although the gold standard of Pmus measurement requires utilization of an esophageal balloon, ΔPocc obtained by applying end-expiratory occlusion can be used to reliably estimate peak inspiratory Pmus.
  • This information can then be used to fine-titrate ventilatory support (Pvent).

Revisiting In-Hospital Cardiac Arrest in COVID Patients – Worth the Effort or Lost Cause? by Zaf Qasim

  • In-hospital cardiac arrest in COVID-19 infected patients carries similar outcomes to similar pre-pandemic events. Therefore, management in this instance should not be seen as futile just because of the COVID-19 diagnosis and does not support the use of a universal DNR.

  • The most common in-hospital arrest rhythm is non-shockable

  • Outcomes are better when the arrest has occurred in the ICU as compared to non-ICU hospital locations, likely due to the more favorable monitoring and staffing ratios

  • Continued study is necessary to elucidate medium- and long-term outcomes in survivors as well as outcomes in health systems outside the US and China

Off-Label Drug Use in Pediatrics by Samantha Dallefeld

  • About half of the drugs used in the pediatric intensive care unit are off-label 
  • Remember these very important considerations when giving mediations to our sick pediatric patients for off-label uses.

Rabies Review: Hit me with Your Best Shot(s) by Ruben Santiago 

  • Human rabies is extremely rare in the US and occurs in approximately 1 – 3 patients annually 
  • Carnivorous mammals, hematophagous bats, and insectivorous bats are the main reservoir for the virus 
  • In the US, the main reservoir species include bats, raccoons, skunks, foxes, and mongooses
  • PEP is essential in the management of these patients and comprises irrigation of the wound with soap and water (and a virucidal agent if possible), and rabies vaccine administration +/- RIG
  • Public health officials should be consulted if there are any questions regarding animal exposure and rabies management

Laryngectomy 101 by Danelle Howard 

  • Laryngectomy stomas are different from tracheostomies and require different patient care.  
  • There is a permanent disconnect between upper and lower airways labeling the patient a total neck breather. 
  • A study concluded HME’s are more beneficial than cold aerosol in this patient population.

The Vitals: The Trauma Primary Survey for the Non-Trauma Doc by Shyam Murali 

  • The trauma Primary Survey is meant to catch common trauma-induced life-threatening injuries and treat them immediately.
  • The Primary Survey consists of evaluating: Airway, Breathing, Circulation, Disability, and Exposure
  • This is just a framework to use when approaching trauma patients and there are many nuances that we will cover soon.

The Unsung Hero of Critical Care ECHO by Manoj Wickramasinghe

  • Echocardiography in critically ill patients is difficult 
  • Often the subcostal view is the only available view 
  • Remember to utilize the various different adapted subcostal views which will make up for the rubbish parasternal views

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