Week in Review: 8/9/20

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Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania, Senior Editor - CriticalCareNow.com, Writer - RebelEM.com, Saxophonist, EDM remixer, husband, puppy father, and new human father

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

Resuscitate Before you Intubate by Babak Behgam

  • Shock Index = HR/SBP
  • Shock Index ≥ 0.9 = associated with cardiac arrest
  • Use the pre-RSI shock index to help identify critically ill patients who are at risk for cardiac arrest following endotracheal intubation.

PEA and Pseudo PEA: A New Proposed Algorithm by Jeff Pepin

  • During PEA arrest, try to differentiate between PEA and Pseudo PEA
  • Identify PREM vs PRES using POCUS checks
  • Evaluate the H’s & T’s for causes of PEA or Pseudo PEA arrest

What is the Oxygenation Index? by Samantha Dallefeld

  • Oxygenation index: OI = MAP x FiO2 x 100 ÷ PaO2
  • Primary indicator for respiratory disease severity stratification in mechanically ventilated pediatric patients

CATscan Dogmalysis (Part I) by Rupal Jain

  • Certain CT scans deliver more radiation to patients than others. Obtaining a CTA of the chest as opposed to a dry CT scan of the chest offers double the effective radiation dose. Similarly, a CT of the abdomen/pelvis with and without contrast delivers double the effective radiation dose of a single-phase CT of the abdomen/ pelvis.
  • CT with contrast should not obscure clinically significant ureteral stones. Just because the ureteral stone is on the differential, you do not have to order a CT both with and without contrast.
  • The indication to order a triple-phase CT is to better characterize liver lesions.

The Vitals: Control Modes of Ventilation Part 1 and Part 2 by Ruth Lamm

  • In control modes, breaths are delivered in one of two ways: by pressure and by volume
  • PCV take-home: you deliver a breath via a constant pressure with the ability to maintain safe airway pressures at the expense of a guaranteed tidal volume (or minute ventilation, since MV=TVxRR)
  • VCV take-home: you deliver a breath with a constant flow rate in order to guarantee a given tidal volume and minute ventilation at the possible expense of safe airway pressures.

Vascular Access During COVID by Harman Gill

  • Prepare for central venous access by selecting the best location and optimizing your ergonomics
  • Consider confirming appropriate placement of your line with agitated saline and cardiac ultrasound

Acute Cor Pulmonale in ARDS – The Conjunction Fallacy by Eduardo Argaiz

  • McConnell’s sign, 60/60, RV>LV are all signs of right heart strain from an acute increase in RV afterload from any cause. They are not specific for PE.
  • ARDS associated Acute Cor Pulmonale is very frequent especially if high driving pressure, high PPlat and high PaCO2.
  • RV hemodynamic optimization could create a safer transfer to CT scanner if high suspicion of massive PE remains.
  • If despite all efforts stabilization is not achieved, empiric thrombolysis could be attempted.


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