Week in Review: 9/20/20

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Picture of Shyam Murali
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:

Mac as a Miller? by Terren Trott

  • The Mac can be successfully used as a Miller.  The ideal context would be when the epiglottis is obscuring the view of the cords.
  • The Mac can be inadvertently used as a Miller leading to a view that’s too proximal to the cords or a blade that obstructs tube passage.
  • Don’t forget to bougie.
  • Check out this CriticalCareNow post about choosing laryngoscope blades

Get in the Zone: Penetrating Neck Trauma Part 1 by Ashika Jain

  • Physical examination regardless of the zone of injury should be the primary guide to dictate further evaluation: CTA vs open exploration
  • Zone 2 injuries are the most common, followed by Zone 1, and then Zone 3
  • Zone 2 is amenable to operative exploration, the others are harder to get to
  • Don’t forget the other vital structures in the neck, ie the airway and esophagus

Vasoplegia: What to do When Your Patients’ Vasculature has the Tone of a Wet Noodle by Colin McCloskey

  • Vasoplegia is a consequence of cardiopulmonary bypass and is defined by a low SVR and hypotension despite an adequate cardiac output.
  • Vasoplegia will resolve with time, but blood pressure support is necessary with vasopressors.
  • Vasopressin and catecholamine vasopressors are good initial choices; steroids, methylene blue, hydroxocobalamin and angiotensin II are salvage therapies.

The Rad Review: Am/Are I MRI Compatible? by Rupal Jain

  • Pearl #1: Non-contrast MRI is safe in pregnancy. Until further research, the consensus is gadolinium in pregnancy is contraindicated. 

  • Pearl #2: Implanted metals carry the risk of: 1) dislodgment 2) thermal injury 3) interference with electrical/mechanical components of device 4) imaging artifacts. 

  • Pearl #3: Make no assumptions about the safety of your patient undergoing MRI examination. Err on the side of caution. Identify the manufacturer and model and visit MRISafety.com and be proactive in discussing potential contraindications with the radiologist.

The Vitals: High Stakes Communication in the ICU by Sunil Ramaswamy

  • Keep a calm mind during the most stressful situations.
  • Keep open communication flowing among the team and delegate tasks effectively.
  • Do not react in anger to perceived mistakes, especially in front of a crashing patient.
  • Remain open to suggestions without being too full of pride. Ask for help when it is needed.

Central Line Tips & Tricks Part 1 by Harman Gill and Shyam Murali

  • Optimize your patient and equipment positioning to ensure procedural success.
  • Use the “Harman Gill Lidocaine Technique” to provide appropriate analgesia for your patient and mark the appropriate location on the neck before draping the patient.
  • As always, practice in the sim lab before your next central line on a patient.

Urine Output and the Machines by Sharad Patel

  • Among all vital signs and labs, UOP was the single most important predictor of mortality. This quick analysis was retrospective, and machine learning feature selection is not without limitations, but it further corroborates the importance of urine output despite the simplified format. Don’t sleep on the Urine output!

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