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Dean Burns

Discussion  - 
 
Dean Burns originally shared:
 
Hi FOAMites

I wanted your thoughts on the inter-hospital transfer of a leaking AAA. Our department hosted a guy in his late 70s with a 9cm AAA which was leaking on CT.

Vascular surgeons are 19 miles away. MAP was 52mmHg, heart rate 72/min sinus. C/O abdominal pain, peripherally shut down.

My instinct was to intubate prior to transfer but two of my anaesthetic colleagues felt it was too risky to tube him & suggested taking him self ventilating, which is what we did. Or was delivered to the surgeons alive & went straight to the operating theatre.

What would you do?
Tube him or risk taking him self ventilating?

I'd love to hear your thoughts.

Dean
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Jordan Schooler's profile photoTrip699's profile photo
7 comments
Trip699
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Dean,

I agree with jordan, don, and scott on this one. However, he is likely going to get intubated in the OR and will have the same risk either in your ED or in the OR to crash. Likely better for him to crash in OR though since he is in the most controlled setting in the hospital.  


Jordan and Scott,

I have been using ketamine only intubation for a while now in my ICU and cardiac units on the hemodynamically challenged preload dependent folks.....Ever since I stated following some website this northern ED/CC doc writes!  props scott. My training in intubations was on the fly when I was a resident and intern.  My training in fellowship was limited due to anesthesia involvement for almost every single airway. We rotated about a month with anesthesia, but intubated in the OR only.  After training I had to improve along the way while moving from state to state and sometimes being the only guy in house other than the ED guy to intubate.  I have intubated in 17 different facilities across the USA and was helped out  A LOT by gracious ED and anesthesia folks.  Man the variance is enormous.  BUT from all of this guidance and personal discovery, I find that in the semi crashing hypotensive patients, the ketamine only intubation has served me very well.  I have only had one episode of severe salivation and this was easily dealt with and had no impact on my procedure.  I have only had one bad result with pressure so far and that was with a pt with critical aortic stenosis and depressed EF of 20 percent.  He had an arrest shortly after just 40 of ketamine and perfect intubation.  The arrest was 15 minutes post procedure possibly related to just ischemia given his decompensating status prior to intubation (pre intubation BP on two pressors was barely 75 systolic.  I suspect I do around 100-200 intubation as year give or take how big a center I am at and in the last year or so I have done most of the semi crashing ones with ketamine.  I agree with scott that paralytics make things simpler the first shot around, but sometimes the hemodynamics just crump when they are too sedate and have no physical assistance with their distress. 


Jordan my approach is the following...
  I will try to get a look in the mouth with a video scope if the patient can cooperate. If i suspect a difficult airway...large person or very anterior anatomy on phyiscial exam, I will try to get a look with a video scope of some kind before the procedure.   I find that sometimes people can allow you a quick glydescope look as long as you talk then through it.  Folks actually tolerate this well in my exp.  I will sometimes use the bronch to do a quick look see and can usually do that with not meds.  Like playing the operation game when you were a kid.  You just place the scope in the mouth and peek over the back of the tongue.  Sounds like a lot of hoo haa to do all this but if the patient is not in certain danger of crashing, I it worth the extra care to make sure you get it right.  I have gone to a few floor intubations and arrived after residents or fellows and find that the blades dont angulate into the mouth.  Some time the op is small and will not permit the usual blade size or the usual glydescope blades to pass.  This can be an issue and IF the patient has been RSI'd you tend to bag the patient while you stand around wondering what next.

 Once I feel good about my airway assessment, then I go ahead with the ketamine and proceed with intubation. I tend to do the pre ox with non invasive vent and place a NC on as well.  For the airway,  I usualy go with a blade first and then switch to glydescope if I have issues.  A bronch is sometimes set up as well if I think i will need it.  I treat an intubation like I treat a bronchoscopy or line etc, I have about everything I need to devour any complication in the room.  I have been burned a few times for assuming that everybody in the room will function effectively in a crisis. I asked for a bougie one time and everybody stared at me...I almost pooped on my brand new cowboy boots.  I try to make the limiting factor the time it takes to grab what I need to take care of any issues.  I may be blamed for over preparation, but It only takes one bad airway to make you find a vacant stairwell and cry...been there and done that. 

hope that answers your question Jordan. 

And once again Scott thanks for the awesome work you and your friends do here on this site and the EMcrit.  It saves lives and humbles me to the point of self provocation to do a little better each and every day I step to the bedside. 


Craig Rosebrock MD
Pulm/CC medicine 
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Christine H

Discussion  - 
 
Hi guys! Have 3 questions regarding your blakemore tube lecture from November 2013. Thank you SO much for the cheat sheet and video - it's wonderful!

1. Someone already asked why you use 2 stopcocks instead of 1 like Dr. Teddei and you responded that your Christmas tree was different (male I believe) and hers was female. Can you help me understand why that difference requires a second stop cock? I am still not understanding why you couldn't hook the tubing onto the end of that first stop cock and have it open to all 3 ports?

2. In your experience, are the Blakemore aspiration ports usually left to low intermittent wall suction? Seems like it would be wise to keep it to suction in case they had stomach bleeding as well. I wasn't sure why it would be a bad idea to have it to suction as opposed to clamped?

3. Couldn't you leave the manometer tubing hooked to the end of the stop cock and leave it open to continuously monitor the pressure in the esophageal balloon? Or would it slowly leak out?

Thank you!!
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EMCrit's profile photo
EMCrit
 
1. Christine, if you draw it out or pick up a 3-way it will immediately make sense.

2. Not sure what you mean, we don't clamp the aspiration port

3. Manometers are notoriously leaky--even good new ones. It is why you need to clamp bp cuffs you use as tourniquets. If you want continuous monitoring, better off with an a-line/cvp set-up.
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Ryan Sullivan

Discussion  - 
 
Hello all,
   I need some help.  I recently have been somewhat blasted in a hospital meeting by two surgeons for my frequent use of subclavian line placement.  I admittedly probably place too many lines in the department, but I am always concerned that they may not have one placed later in their hospitalization, and that they may in fact become "sick".  I obviously do US guided IJ's, but depending on the patient I sometimes just prefer subclavian..."line of champions"...
Can you guys please help me with literature search supporting subclavian line placement?  I fear this will escalate and I want to be more prepared.  thanks so much!
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Ryan Sullivan's profile photoTrip699's profile photo
17 comments
Trip699
 
no problem at all... 
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Mark Rostash

Discussion  - 
 
Thank you Drs Weingart and Drummond for the reply on EtCO2 debate in my facility.  Going to present some new resuscitation ideas to the group here and wondered who was using vaso/steroid/epi therapy during resuscitation, and if so what dosages.  I reviewed the Greek VSE studies, are those the only to date?  And Dr Weingard, how would you suggest that I present these new ideas without offending or medical group (as I am an RN, and not wanting to imply that I am attempting to tread on their turf)?  I simply want the best we can do for our patients, and help set the bar higher for the education and training of all involved
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Joe Bellezzo's profile photo
 
For our +ED ECMO patients, I use VSE. I believe there is a role for epi (alpha stim) and use it sparingly (hemodynamic-guided via art line); I'm also a strong believer in Vasopressin for profound shock and cardiac arrest, so I use that too - regardless of the Greek VSE trial.  Adding a whisper of solumedrol isn't going to hurt anything...and the VSE trial was compelling. So, I use VSE.  FYI I also start vaso very early in profound shock too.
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Hi.
I'm hoping you guys might be able to help me on a clinical question.

The other night I had a septic patient. He had an RF of 36, atrial fibrillation with a HR of 110-130. Normal BP. So not terribly sick.

I start fo administer fluids. AB is on board already. And we put in a catheter to monitor urinary output.
After the first 1500cc he starts improving. But before that his output is 85 mL over 4 hours. I'm thinking he just needs some more fluids.
The nurse asks if I want for administer furosemide to stimulate. I'm thinking that the patient needs fluids so surely that would be a step back.
From what I understand stimulating with furosemide is only good for making the staff happy about urinary output but does not helt the patient.

Afterwards a more senior resident suggests furosemide as well. Something about flushing some fluid out to improve heart function, and then more fluids can be given if needed.

So I'm lost. Does it make sense to administer furosemide to simulate urinary output and get a "fluid turnover" of some kind?

I hope someone can and wants to spend the time to answer. Thanks in advance!
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David Lindfield's profile photoAndy Drummond's profile photo
19 comments
 
Now, that would be over cooking things a bit :-P
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Hi Dr. Weingart, 

I'm an EM resident from Michigan who has worked on our hospital's sepsis committee for the past 2 years. I proposed the attached triage protocol that I believe you use for the NY sepsis collaborative about 2 years ago, but finally got buy-in from my administrators to move forward with it. I just wanted to confirm that it is still what you use...

If not, what are you using? 

Are the docs in favor of it? Or are any frustrated by more lactates getting ordered on patients who may not end up having a septic process going on? How about nursing staff? Trying to anticipate some push back from my colleagues...

Thanks for what you do. It has been a huge supplement to my education so far.
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EMCrit's profile photoNicholas Mulcahy's profile photo
2 comments
 
Ok great. Thanks for the quick response.

That's good to know that those fast track pts aren't getting this. Can't wait to start using it!
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Lindsay Grubish

Discussion  - 
 
I am a resident working on an project involving the use of tactical breathing during ET intubation. I believe I heard something similar on EMCRIT in the past. What are your thoughts? 
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Marc August's profile photoLindsay Grubish's profile photo
3 comments
 
Thank you for the awesome suggestions. 
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I have my debut as Twitter moderator for a critical care meeting I September. Any word of advice from the community ?
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Søren Steemann Rudolph's profile photoMinh Le Cong's profile photo
3 comments
 
use specified hashtag
dont be rude or abusive
respect patient confidentiality
above all do not bring profession into disrepute
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Ellen Stein

Discussion  - 
 
I have a question about pressors and afib.  I had a cardiac arrest pt with unclear pre-hospital rhythm (thought to be afib originally then pea) who experienced ROSC. He then went into afib with rvr (140s).  We cardioverted as he was also hypotensive (no clear PE or any other treatable cause).   He converted to normal sinus (HR 70-90).  He remained hypotensive  despite fluid boluses so we started him on levophed but he kept bradying and going back into PEA, but would get pulses back with epi boluses.  Question:  would an epi drip have greater chance of inducing the afib with rvr or would that be okay as our pressor, since he clearly benefitted from the epi for his cardiac function and he needed a pressor.
 And yes...we did eventually  stop resuscitation once the family was mentally ready.   Thx!
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Trip699's profile photoEllen Stein's profile photo
7 comments
 
Thanks for your input!
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Matthew Hogan

Discussion  - 
 
Hi all.  I am a flight Paramedic and educator in Saskatchewan, Canada.  I was recently discussing John Myburgh's lecture on SMACC with a colleague.  I was doing my best to describe the concept that Vasopressors like Norepi lead venous constriction in addition to their arterial effects.  I was just wondering if anyone can recommend any resources (articles, videos) that do a good job of explaining the physiology behind this concept.  Thank-you in advance for your help!

Matt
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Iwan Dierckx's profile photoTrip699's profile photo
10 comments
Trip699
 
At the end of the day the body performs in a complex way.  I was an organic chemist for a few years before med school.  Synthesis on paper was not always translated along the way when you go to the bench top. I suspect that we assume a lot sometimes from studies that may or may not be how it all goes down.

just means we have more to learn about the complex system of life 
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Joshua Bigler

Discussion  - 
 
I had a question on LR infusion. If I have my understanding right LR with the 4 meq/L potassium should not elevated the potassium significant in a patient with renal failure even in the setting of hyperkalemia. My reasoning is that due to the low SID and dilution of potassium from the 1L with less hydrogen potassium cellular shift you should see minimal to no elevation of potassium. Much like people talk about the mmol of lactate have negotiable effects on the total lactate amount even in the face of a poor cori cycle such as liver failure. What is your experience?
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Jordan Schooler's profile photo
3 comments
 
I don't have any personal experience with this because no one will let me give LR to hyperkalemic patients. I'll let you know after I become an attending. 
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About this community

The place for EMCritters to share cases and ideas on resuscitation, ED critical care, and trauma.

Trip699

Discussion  - 
 
Other than pressors and fluids (albumen, NS, LR etc) can you guys think of any way to increase blood pressure in a patient refusing blood and blood products with a Hg of 5 (bleeding controlled intra op) and BP of 55 systolic and 20 diastolic?

other labs
Lactate 16
Cr. of 4
PH of 7.01 all metabolic.

thoughts?
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Ryan Sullivan's profile photoTrip699's profile photo
11 comments
Trip699
 
michael
some JW's will accept albumen but this one would not.  
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EMCrit
owner

Discussion  - 
 
EMCrit originally shared:
 
Podcast 156 - The Central Line Show--Stop Effing up your lines

Stop Effing Up Your Central Lines
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Ask the EXPERTS - Join the live feed - from the International Symposium on Critical Bleeding in Copenhagen - ISCB2015 

31.08.15 - 12.15 CET
01.09.15 - 12.15 CET

Dr Jakob Stensballe will host a panel of the worlds foremost experts on bleeding and coagulation - Prof. J.B. Holcomb, Prof. J.R. Hess, Prof. R.P. Dutton,  
Prof. T. Lisman, Prof P Johansson and Dr S Ostrowski

Don’t miss out on this event

Follow us and be ready with your questions via Twitter #iscb2015  @iscb_2015
It is a pleasure and an honor to invite you back to the 5th International Symposium on Critical Bleeding August 31st - September 1st 2015 (ISCB 2015). Critical bleeding remains a major cause of potentially preventable deaths. Even though the treatment paradigms have changed considerably during ...
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Minh Le Cong's profile photoGlen Ellis's profile photo
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Mark Rostash

Discussion  - 
 
Had a question regarding placement of the sidestream EtOC2 detector for continuous wavefrom capnography. I have used it for every single intubation for years now. My new hospital is barely using for any, and i have pushed for it since day one. I am being told by RT folks that my placement location is incorrect. As i was trained, we were told that sidestream should be to the vent side of the HME to keep moisture from clogging the small exhaust port. They are stating that this location is incorrect and altering the readings. I have zero data to support either way, but this is how i was trained by a director of trauma anesthesia from a previous place of employment. Could you weigh in, or provide me a link to some data.
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EMCrit's profile photoAndy Drummond's profile photo
2 comments
 
Yes, I'd always put sidestream on the vent side of the HMEF to prevent contamination of the capnograph (in fact, the HMEFs we use in ICM and theatres have a port for connecting the CO2 line on the vent side).

Mainstream can go either side as the contamination issues don't apply, and can be used with a 'wet' (humidified) circuit.
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Iwan Dierckx

Discussion  - 
 
Been thinking about peri-mortem C section. My guess is that PE is quite a common cause for arrest in pregnancy. So how would you run the code: C section and forego tPA or thrombolyse and no C section ? (didn't  include ECMO as an option, seeing as we don't have it available)
12 votes  -  votes visible to Public
tPA: yes / c section: no
17%
tPA: no / c secion: yes
83%
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Lewis McLean's profile photoDominik Daszuta's profile photo
10 comments
 
+Lewis McLean did it take long from starting the code to delivery? How many personel involved? 
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Rob Adams

Discussion  - 
 
Hi All. I am working as a Dr in clinical trials and have just started screening healthy men (18-55) but with the dangerous addition of a high sensitivity Trop T.
A 38 yr old gentleman, who had a full medical performed by myself, Normal ECG. Normal vitals, normals labs.
Now has a trop T of 21 (ULN 14 ng/L)

How would you suggest handling cases like this?
Thanks in advance
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Dominik Daszuta's profile photoJohn Pickering's profile photo
4 comments
 
In our studies we would inform the patient's general practitioner of any abnormal results (patients consent to this before admission to the study).  There are those with chronically elevated troponins & amongst those who turn up in hospital with elevated trops but no ACS there are poor 1 year outcomes. See, eg, 14. Mc Falls EO, Larsen G, Johnson GR, Apple FS, GoldmanS, Arai A, Nallamothu BK, Jesse R, Holmstrom ST, Sinnott PL. Outocmes of hospitalized patients with non-acute cornary syndrome and elevated troponin level. Am J Med 2011; 124:630-35. 
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Jason Pierce

Discussion  - 
 
I have been listening to your podcasts for awhile now and learning a lot.  Thank you very much.  I am a flight nurse in Ohio and wanted to see if you have recommendations for meds for RSI for the pregnant patient.

Thanks
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Jason Pierce's profile photoJeffrey McCall's profile photo
9 comments
 
We use etomidate and half-dose in shock. I would love to have ketamine for our shock pts but haven't been successful in convincing our medical director for that yet. We did get roc when we had the vec shortage last year. 
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I have a question concerning lactates in the ED.  How many are using Point of Care lactates to expedite sepsis screening?  If you need to re-check a lactate and do not have POC on the floor, do you follow-up with a serum lactate? 
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Trip699's profile photoJeanie Bollinger's profile photoroberto cosentini's profile photo
2 comments
 
Thank you Craig. We are working on our sepsis screening process and are evaluating how we can consistently get screening lactates done fast and at a low cost. 
Jeanie Bollinger Clinical Nurse Specialist
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Trip699

Discussion  - 
 
Just wanted to open up a thought discussion on the following.
Have you guys been going forward with the cardiac arrest to the cath lab algorithm?
Thoughts?

http://rebelem.com/beyond-acls-cpr-cath-new-accaha-cardiac-arrest-algorithm/
Cardiac Arrest: Should we cath all patients with Out-of-hospital cardiac arrest (OHCA) and return of spontaneous circulation (ROSC) who are still comatose?
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Jordan Schooler's profile photoTrip699's profile photoJustin Stratton's profile photoEmsstat Field Training's profile photo
2 comments
Trip699
 
yep Jordan.  My thoughts are similar.  
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