Week In Review: 8/01/21

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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:

A Bedside Perspective of EVDS by Caitlyn Stough 

  • Only do a cuff leak test if your patient is at a high risk for post extubation stridor. If your patient fails the cuff leak test, repeat, and give steroids 4-6 hours prior to extubation and do not repeat the cuff leak test.

Airway Squeaks and Cuff Leaks by Komal Parikh

  • Only do a cuff leak test if your patient is at a high risk for post extubation stridor. If your patient fails the cuff leak test, repeat, and give steroids 4-6 hours prior to extubation and do not repeat the cuff leak test.

High Dose Naloxone: Is it Evidence Based by Simon Taxel

  • Naloxone administration is one part of a comprehensive treatment strategy when a patient is suffering from opioid overdose.
  • While fentanyl and its analogs are extremely potent, there is little to no evidence to validate the claim that high-dose naloxone is useful in the clinical setting.   
  • If a patient’s altered mental status and respiratory depression are persistent after the administration of naloxone then medical providers should have a high index of suspicion for additional complicating conditions such as polysubstance ingestion, as well as cardiac, pulmonary, or CNS pathologies.

Sepsis-Induced Cardiomyopathy by Fraser Mackay

  • Consider SICM in patients with septic shock who are not responding/ worsening as vasoactive doses increase. It is often underdiagnosed, so check early.
  • SICM affects a small but significant population of critically ill patients. Middle age as well as a history of heart failure are risk factors.
  • SICM needs prompt treatment/ recognition and timely access to echocardiography or point-of-care ultrasound is paramount. 
  • Balance judicious preload with moderate afterload when dosing vasopressors, using inotropes to augment contractility once vascular tone is restored.
  • Consider early referral for ECLS in patients with refractory cardiogenic shock but otherwise good prognostic indicator. 

Management of Status Epilepticus by Rachel Rafeq

    • Medication therapy should be initiated as soon as possible to avoid preventable treatment failure 
    • High-quality evidence supports lorazepam 0.1 mg/kg IV as first-line therapy. When IV is not an option use midazolam 10 mg IM.  
    • Consider loading with an antiepileptic drug such as levetiracetam, valproate, or fosphenytoin concurrently with benzodiazepine therapy or immediately after.
    • Remember getting the drug on board fast is key so don’t waste time waiting for an EEG or obtaining premixed bags from the pharmacy. Use what’s available in the ED to allow for prompt administration.

ROX’ing with HFNC by Sabrina Kroft 

  • S/F ratio can be utilized  as an alternative to the P/F ratio
  • The ROX index allows practitioners to quickly assess patients for possible HFNC failures
  • The ROX index is just one of many assessment tools needed for proper care of Acute Hypoxic Respiratory Failure patient. 

The Vitals: How to Protect the Lungs – Intro to Management of ARDS by Sunil Ramaswamy

  • Lung protective strategy has been proven to reduce mortality and increase ventilator free days in mechanically ventilated patients with ARDS. 
  • The key number to remember is 6 mL/kg of predicted body weight (which is based on the patient’s height).

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