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hi, please recommend guidelines or personal experiences on the use of antibiotics in cardiac surgery, thx!

Hi FOAMed people

Can anyone recommend a therapeutic hypothermia device?

Ideally looking for something portable & simple (but more sophisticated than ice packs) to maintain TTM.

Ideally, should be able to rewarm cold people & cool down warm people.

Any guidance/experience you've had with these devices would be helpful.

BW

Dean

Hey guys!!

I've recently published an iBook pertaining to the basic vectors and electrophysiology surrounding the ECGs. It is a very visual resource with rich videos, animations and whiteboards to keep the learner engaged at all times.

https://itunes.apple.com/gb/book/basics-of-the-ecg/id1118593363?mt=11

Thought I'd share it here. Feel free to use it in teaching if you think it would help your students!!

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Here the ecg earlier post
Photo

I have. A few questions on a case i just got last night. I forgot to bring the ecg but will try to send one later.
It's an elderly gentleman with a complete heart block hx of syncope x2 in the last 2 days.
1) the atrial rate looks like atrial flutter. The cardiologist state it can't be call such because the ventricular rate is to slow (35-38 min)??
2) he remain HTN at 210/75 with wide pulse pressure despite NTG drip,captopril and his regular BP medication. According to cardiologist, his BP is a compensation for the low HR. Wouldn't he be low BP due to low Cardiac output?? What would be the advantage for the body to keep itself at a Mean of 115-120??
3) with the story of syncope, widening pulse pressure and heart block could it be warrant of a work up for vascular emergency like dissection??

Hi FOAMites

I'd like to hear your views on a difficult clinical case that ended poorly.

It concerns a 6 year old girl who presented really sick after a week of chickenpox. She was seen at our ED yesterday with a fever and was evaluated, given anti-pyretics and sent home. She returned today in extremis, hypoglycaemic, hyponatraemic, hyperkalaemic, acidotic and a lactate of 8 mol/L with renal impairment. She was covered head to toe in some green lotion, believed to be Camomile lotion, with Russian language writing on the bottle.

2 x 24G IV were placed - her peripheries were ice cold and her BP unrecordable.

She was fluid resuscitated with 0.9% saline, given acyclovir, ceftriaxone, and flucloxacillin IV. Her high potassium was managed with calcium gluconate, and NaHCO3 and salbutamol nebs. The paediatricians were reluctant to give insulin dextrose (because of her initial hypoglycaemia) so that was held. She continued to deteriorate, her metabolic acidosis worsened. Peripheral dopamine was started and a Foley catheter was placed in her bladder. The retrieval team arrived and an IO needle was placed and an adrenaline infusion was started. A CVC placed in her left femoral vein but placement of an arterial line failed in both femoral arteries as the child was extravasating all of the fluid she received and becoming very oedematous. She underwent RSI with ketamine and rocuronium and keeping a MAP of around 50mmHg. She continued to deteriorate, lost her BP and arrested.

She was Rx with insulin IV pushes and CaCl via the CVC and had ROSC after a single shock (she went from PEA to VF). Her potassium failed to respond to pushes of insulin and further calcium and she experienced 3 further cardiac arrests.

Finally, she was transferred to the tertiary centre PICU for ECMO/CVVHD but died en route.

I work in a centre with no PICU and have a number of issues I'd like to discuss.

1) Leadership in these scenarios. Present in the room were myself (ED/ICU Consultant), the ICU Consultant and a Paediatric Consultant. The question of who leads these scenarios is something I find personally difficult. I am relatively inexperienced as a Consultant and I was working with 2 Consultants with more than 10-20 years more experience than I. How do you do this?
Do you agree a leader at the beginning and then go from there?
Does the ED Consultant always lead if other more experienced colleagues are present?
2) Management of hyperkalaemia in kids - I've not come across a cardiac arrest in a child 2ary to hyperkalaemia. How quickly to you run an infusion of insulin/dextrose? We were giving 2 units of insulin IV blouses and drew up an infusion of 0.1units/kg insulin with 5mL/kg of 10% dextrose. How quickly do you run this infusion? Over 10 mins, 30 mins?
I'm not certain.

3) Has anyone seen anything similar to this before?
Toxic shock on a background of chickenpox - we don't have a cause of death yet.
Blood culture results are still pending. Blood results were quite abnormal, with a CRP of 270, INR 3.5, APTR 3.2, and an unrecordable low fibrinogen.

I'd appreciate your observations on leadership when you're starting out as an attending/consultant & you're the least experienced of your grade in the room. Any FOAM resources you could point in my direction?

How do you manage life-threatening hyperkalaemia in septic kids in renal failure?
We have no PICU at our hospital and so no ability to filter kids for hyperK. How do you feel about peripheral pressors in kids?
Do you place IO needles as a quick means of starting pressors?
What's your preferred pressor/vasoactive medication for these kids?

I have so many questions about this case. Thanks for taking the time to read it.

Best wishes

Dean

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Discover Acute Heart Failure’s therapeutic pipeline, drug profile and key players involved

#Health care #HeartFailure #drugs

Question about blog post on polypharmacy and lack of research in long term risks and benefits of cardiac medications - what was the blog?

Dear FOAM community,

About 6 months ago I read an excellent blog post, linked to an excellent journal article, about how little research has been done on the risks and benefits of medications (especially cardiology meds) after a few years. The authors proposed there was probably more risk and and less benefit as time goes on. I'm now preparing a grand round presentation on polypharmacy, and want to include this article, but just can't remember were I read it! 

If any FOAM experts could remind me I'd be very grateful.

Dear FOAM community

I was wondering if anyone out there has a particularly robust and efficient x-ray filing system for reviewing radiologist's reports.

I'm in the process of revamping ours and wondered if anyone worked in departments with very efficient filing systems I could discuss the process and challenges with.

Thanks & happy holidays

Dean
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