Week In Review: 7/04/21

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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:

If You ROC Your Patient, ROLL with Sedation by Steve Haywood

  • Paralysis without sedation causes psychological harm to patients. 
  • Known the duration of action of the paralytic and sedative agents you use
  • When dosing a long acting paralytic, start infusions of analgesia and sedation immediately after dosing your paralytic

Vasopressors For Nurses by Tyler Jones

  • It is essential to know the reason why we use vasopressors in each situation.
  • Alpha-adrenergic agonists are mainly vasoconstrictors and increase SVR.
  • Beta-adrenergic agonists increase inotropy and bronchodilation.
  • Vasopressin for distributive shock exerts effects on the kidney and vascular smooth muscle.
  • Watch for potential arrhythmias and adverse events that can come from vasopressors.
  • Part of that elevated lactate could be coming from your vasopressors, particularly epinephrine, though this is not necessarily pathological.
  • When patients do not respond to initiate therapy, it is important to investigate why this may be: is our diagnosis wrong, is there cardiac dysfunction, etc. This will require collaboration with your APPs, pharmacists, and physicians at the bedside.

Cooling After Out-Of-The Hospital Cardiac Arrest: The TTM2 by Shyam Murali amd Mohamed Hagahmed 

  • Protocolized care that focuses on achieving hypothermia (32C-33C) is not supported by current evidence and may confer risk without clear benefit. Active temperature management targeting normothermia and avoiding fever makes more logical sense; however, further studies need to be conducted to actually determine if targeted temperature management (at normothermic temperatures) actually has any benefit.

Classic Studies in MCS: The Advanced Trial by Colin McCloskey

  • The third generation, continuous flow, centrifugal pump is non-inferior to its continuous flow axial forebears. This laid the groundwork for two randomized control trials comparing the designs, Momentum 34 and Endurance5.

Revisiting The Flipped Classroom by Zack Repanshek

  • So what is the Flipped Classroom’s role in medical education today? While no longer the sensation that it once was, it should still be part of the armamentarium of the skilled educator. It is a valuable format that allows for both foundational and higher-level learning. Utilizing the Flipped Classroom promotes engagement and active learning, and allows the educator a level of freedom and creativity that traditional teaching methods do not.

Bones Over Veins: Intraosseous Access by Nishika Patel 

  • The IO route is the fastest way to infuse fluids, medications, and blood products in emergency situations including cardiac resuscitation.
  • IO dosing of medications is equivalent to IV dosing.
  • Pressure bags or rapid infusion devices must be used to ensure medications reach the central vascular system; manual compression of IV bags is not sufficient.
  • IO labs should be drawn before treatments are administered through the IO site to prevent false values secondary to dilutional effects.
  • The humeral IO site offers the highest flow rate and confers the least amount of pain based on current literature.
  • Pain should be preemptively treated with the use of 2% preservative-free lidocaine flushed through the IO port

Treatments Beyond Albuterol by Stephen Biehl and Rahel Gizaw 

  • Symbicort Turbuhaler has been shown to be superior as a rescue inhaler than albuterol in asthmatics
  • Albuterol PRN as the sole use of treating asthma increases the risk of having severe asthma exacerbations
  • The use of Symbicort Turbuhaler in children has been shown to be effective in treating asthma exacerbations

Obesity and Respiratory Mechanics by Obiajulu Anozie

  • Central obesity is associated with altered respiratory mechanics that complicate the management of critically ill patients.
  • Increased intrapleural pressure and reduced diaphragmatic expansion leads to reduced TLC, ERV and FRC. The FEV1/FVC ratio is, however, normally preserved 🡪 Restrictive Lung Defect
  • Increased airway resistance results when FRC drops below CC causing small airway collapse.
  • Those patients may show expiratory flow limitation and reduced FEV1 🡪 Mixed/Obstructive Lung Defect

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