Week In Review: 9/12/21

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Picture of 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:

Proning and it’s Benefits, for Nurses by Tyler Jones 

  • Lung protective ventilation and proning are the only interventions shown to reduce mortality in ARDS.
  • If you notice this reduction in P/F ratio early in the course of illness make sure to advocate for pronation for your patient
  • When proning, have plenty of help to ensure safety.
  • Place mepilex anywhere a pressure injury may occur
  • EKG leads to be taken off and placed on the back in reverse fashion.
  • Know complications to watch for once proned.

Mastering the Vent Cycle: Cycle Dyssychronies by Matt Siuba

  • Cycle refers to the end of inspiration (beginning of expiration). 
  • When we name vent dyssynchrony issues as “early” or “late”, the patient is the reference. E.g. if the vent is late to cycle relative to the patient, it is late cycling.
  • Early cycling requires clinical judgement to decide how best to ameliorate it
  • Delayed cycling is generally easier to fix, especially in conventional pressure control where you just need to shorten the inspiratory time to match the patient’s neural inspiratory time. 
  • However, understanding flow cycling for patients in pressure support is key to making proper adjustments. More on that topic here.

Hypertonic Saline (HTS) or Mannitol: Salty or Sweet? by Kevin Yeh

  • Both HTS and mannitol are effective in decreasing ICP; however, one must consider the patient presentation.  HTS is an effective volume expander while mannitol is an osmotic diuretic, thus, HTS should be preferred if there are needs for resuscitation.  However, because elevated ICP is considered a neurologic emergency, whichever agent is readily available should be administered.  Serial sodium monitoring should be performed with HTS therapy as rapid changes in serum concentrations may lead to osmotic demyelination syndrome.  Patients on prolonged mannitol therapy are at risk of acute kidney injury – be sure to measure serum osmolality gaps.

Valproic Acid..for Delirium?  by Nichika Patel 

  • Delirium is associated with significant patient morbidity and mortality as well as increased hospital LOS and long-term cognitive impairment. 
  • VPA is an effective alternative for patients who cannot receive antipsychotics or dexmedetomidine for delirium treatment. 
  • VPA dosing for delirium varies from study to study; however, a review article written by  Sher and colleagues recommends that adult patients receive 250 mg PO/IV daily in the morning, 250 mg PO/IV daily in the afternoon, and 500 mg PO/IV daily before bedtime and that elderly patients receive 125 mg PO/IV daily in the morning and 250 mg PO/IV  daily before bedtime. 

How is Your Driving? by Sabrina Kroft

  • In addition to protective lung ventilation, measuring driving pressures can reduce injury to the lungs
  • Dynamic changes in the lungs affect the driving pressure
  • Accurate measurements are key to success when calculating the driving pressure

ResusX:ReWired The Magical Lewis Lead by Jessica Andrsaitis

  • Lewis lead is a modified ECG lead that augments the analysis of atrial activity
  • Useful when trying to determine VT vs atrial tachycardias
  • Here’s how to do it:
    • Move RA to the mannubrium
    • Move LA to right 5th intercostal space next to sternum
    • Move LL to right lower costal margin
    • Lewis lead is read on lead I (but look everywhere for atrial activity)


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