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hi, please recommend guidelines or personal experiences on the use of antibiotics in cardiac surgery, thx!
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Jon Steuernagle's profile photo
 
Decontaminate the nasopharynx per-op! :)
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Dean Burns

Discussion  - 
 
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


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Jon Steuernagle's profile photo
 
I have been a fan of the Arctic Sun machines. Non-invasive gel pads attached to patients do a good job cooling and warming. I have used the GayMar systems of blankets, which are cumbersome I have used an invasive catheter system as well the Zoll Thermoguard.
As the RCT data shows neuroprotection more of a factor of maintaining eu-thermia and less of getting to an absolute cold temperature quickly (33ºC), invasive methods, which were already shown to be non-superior, become even more dubious, IMO.
I'd like to think, with risks of CLABSI etc..we would become less invasive where it is supported by good evidence.


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TheMountainRN

Discussion  - 
 
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??

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Dean Burns

emergency medicine  - 
 
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

1
Damian Roland's profile photo
5 comments
 
Terribly sad. Truly dreadful disease that is virtually impossible to predict. 
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Neha P

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

#Health care #HeartFailure #drugs
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Dean Burns

emergency medicine  - 
 
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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Dean Burns

emergency medicine  - 
 
 
Hi ED FOAMites

I'm aware of a prevailing culture of not calling the ED Consultant/Attending overnight when catastrophe strikes on our department. This is likely a historical hangover from when we had only 2 Consultants, we now have 8.

Does anybody have a written protocol, didactically describing the triggers to discuss a case with the Consultant/Attending.

A recent case of a 28 year old in blunt cardiac arrest wasn't discussed until 45 mins after arrival.

I'd like to hear of any successes in changing culture and what threshold you set that these cases must be discussed with the on-call ED Cons/Attending.

Thanks

Dean
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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
1
Andy Drummond's profile photo
3 comments
 
What they said. The time to intubate this chap is on table with the surgeons scrubbed and ready to go.
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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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Jon Steuernagle's profile photoDamian Roland's profile photo
2 comments
 
Be quite diligent about checking timelines and making sure everyone is aware of hashtags etc. A lot of people 'join' twitter at conferences but don't always get the gist of it initially. I've seen people get frustrated and give up quite easily and also seen very friendly moderators garnish real engagement in those initially unsure by being very pro-active in their approach. But above all have fun yourself - it shouldn't be a chore!
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Andy Drummond

critical care  - 
 
What criteria do people use for diagnosing #VAP? CPIS, clinically, or something else?
1
Jon Steuernagle's profile photo
2 comments
 
My favorite part of this "quality measure" - However, there is currently no valid, reliable definition for VAP, and even the most widely-used VAP criteria and definitions are neither sensitive nor specific. #awesome  
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TheMountainRN

Discussion  - 
 
Interest piece by the economist
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About this community

FOAMcc is the community for critical care free open-access meducation. It is moderated by Chris Nickson, John Greenwood, Minh Le Cong and Scott Weingart. The FOAMcc G+ community is supported by the affiliated blogs, podcasts and websites linked below. This is a place for the sharing and post-publication peer review of FOAM resources, dissection of hypothetical cases and the discussion of all things critical care. Check out the #FOAMcc hashtag on Twitter. Remember to preserve patient confidentiality at all times — do not discuss identifying details of cases, only hypotheticals and generalisations. If sharing a link provide an explanation why it is relevant to the FOAMcc community and use it to initiate discussion. Vive la FOAM!

U Bhalraam

Discussion  - 
 
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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TheMountainRN

Discussion  - 
 
Here the ecg earlier post
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5 comments

James Garvey

Discussion  - 
 
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.
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Andy Drummond

intensive care  - 
 
Does anyone have a formal protocol for a trial of volatile agents in bronchospasm that they'd be willing to share? Thanks
2
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Martin Sundström

critical care  - 
 
Hi everyone,

Looking into alternatives for a small transport ventilator to be used for intrahospital transfers, mainly from ER to ICU. Requested specs:
- Highly portable (smaller than oxylog 3000)
- Delivers a reliable minute volume w optional PEEP
- Possible to use for NIV/BIPAP

So far only looked at Pneupac VR1 (too simple) and Oxylog 1000 (not sure if it can do NIV?). Other suggestions? Advice is much appreciated.
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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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TheMountainRN

Discussion  - 
 
I an preparing a lecture on heart failure. While doing my reading there seem to be 2 really opposite school on the subject: on one side everyone get diuretics and in some case vasodilatation can help vs maximize your vasodilatation before using diuretics. What are you opinions??
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TheMountainRN's profile photoJon Steuernagle's profile photo
4 comments
 
Overload typically broken into intravascular and extravascular and can be completely independent. Sometimes with RV failure, obesity/overweight, poor nutrition/low albumin can be hard to gauge. The classic LV systolic heart failure (Low EF HF) = rales, LE edema, pulmonary vascular congestion, hypoxemia, dyspnea/tachypnea, PND/orthopnea. If not actively ischemic mainstay of therapy is afterload reduction, diuretics and a tincture of time. Then beta blockers and figure out why they went into HF.
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TheMountainRN

resuscitation  - 
 
interesting concept
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TheMountainRN

Discussion  - 
 
In the new hospital i work they use digoxine a lot for A-fib, mostly the medicine department. It’s a big contrast from my previous shop where it was almost evil to use it.  what’s your practice??

For example, yesterday we get this 91 years old elderly in hyperosmolar non ketone acidosis with suspected urosepsis. He slightly improved with fluids and  insuline but then went into,a rate of 150 ( suspected atrial flutter) and drop his BP in the 80’s despite keeping a map 65-70. Medicine decide to treat with digoxin 0,5 mg.
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