Week In Review: 8/08/21

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Reading Time: 3 minutes
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 Many Faces of Multiple Triggering by Matt Siuba 

  • Multiple triggering is associated with worse outcomes; whether it is causative is unknown. Either way, mitigating it would be beneficial for patient comfort and to possibly decrease risk of ventilator-associated lung injury
  • Not all “breath stacking” has the same cause which is relevant as the treatment for each type will differ
  • More sedation is not the answer for all dyssynchrony! In fact, a recent study showed the respiratory drive and depth of sedation are not necessarily well correlated.

Point of Care Ultrasound by Allan Lai

  • POCUS findings at the bedside can help nurses anticipate and predict patient care.
  • Ask your colleague to communicate their POCUS findings to you.
  • POCUS does not replace formal medical imaging; plan for road trips. 

Ischemic VSD by Colin McCloskey and Sam Epstein

  • VSD is an uncommon but morbid mechanical complication of acute myocardial infarction
  • Mechanical circulatory support can offer a bridge to repair
  • Repair options include cardiac surgery and transcatheter closure. The ideal approach and timing is decided on a case by case basis
  • The American Heart Association recently published a guideline for mechanical complications of AMI, give it a read.

What is Digital Scholarship? by Zack Repanshek

  • Digital scholarship is a relatively new term to describe educational content that exists in the digital space. Like more traditional formats, its value derives from its originality, its ability to be disseminated and commented upon, and its role in advancing the field of medical education.

  • In future posts, we will look at identifying and capturing digital scholarship, and the role it plays in the promotion process.

Wooden Chest Syndrome by Nishika Patel and Rahel Gizaw

  • WCS is a rare complication in patients receiving lipophilic opioids such as fentanyl
  • WCS causes chest and abdominal muscle rigidity leading to ineffective spontaneous ventilation and difficult assisted ventilation with elevated airway pressures
  • Risk factors for WCS include concomitant use of medications that modify dopamine levels, extremes of age, high cumulative doses of fentanyl, rapid IV administration, critical illness, and use of lipophilic opioids 
  • Management of WCS in the non-intubated patient includes discontinuation of the opioid (with or without naloxone reversal) and supportive ventilatory care
  • Management of WCS in the intubated patient includes discontinuation of the opioid, replacement of the opioid with a non-lipophilic version such as hydromorphone or morphine, addition of a non-depolarizing paralytic infusion for at least 24 hours, and supportive ventilatory care
  • Waiting at least 24 hours after cessation of fentanyl to attempt extubation in a WCS patient is recommended
  • Having a history of WCS does not preclude the use of fentanyl or related opioids in the future

Pushing the Limits of Hypoxia by Gene Macogay

  • The human body’s ability to adapt and compensate in adverse conditions is nothing short of amazing!
  • There is a more to blood gases than pH, PaO2, PaCO2, and HCO3
  • Hemoglobin matters
  • Look at the whole picture

The Vitals: To be a Great Proceduralist, be a Great Assistant by Bassam Zahid

  • In order to be a great proceduralist, one must also learn to be a great assistant.
  • The best assistants take care of the intangibles in the room that the proceduralist might be too busy to think about: Is the bed at the correct height? Is the ultrasound in the proper position? Is there unnecessary noise? Is the patient comfortable?
  • The ideal assistant knows to anticipate problems before they arise and where to find more equipment should it be required.
  • An essential task of the assistant is to recognize when to stop the proceduralist or to call for backup if the proceduralist is having trouble and letting his ego get the best of himself.
  • By practicing how to be a great assistant, proceduralists will become better at performing interventions when they do not have help readily available.

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