Is it vasospasm?
Clinical Pearl: The most important tool in the Neuro ICU isn't the TCD or the CTA—it's the hourly neuro exam. Vasospasm management is a 21-day art form. What’s your "must-check" at the bedside?
Comment to discuss.
Post-Intubation Hypotension in Status Epilepticus
-BP often drops w/ propofol post-intubation
-Avoid turning down propofol: likely seizures will restart
-Instead, add vasopressor: hypotension secondary to vasodilation/decr cardiac contractility
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Knee dislocations: high risk for popliteal injuries which can be limb threatening
-Obtain ABIs. If ABI less than 1.0 proceed to CTA
-Skip right to CTA if high suspicion (ie weak pulse)
-Be cautious of the spontaneous reduction prior to presentation
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The use of steroids in septic shock has been debated for decades, but more recent data increasingly supports their benefit (PMID: 38250247), particularly for patients in refractory vasopressor shock.
AVAPS - ensures pt gets a set volume
-Set EPAP + 2 X IPAP (low + high)
-Machine will vary IPAP to ensure delivery of volume
-My approach: start w/ BPAP. If pt not improving or tolerating, switch to AVAPS + discuss w/ resp therapy
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Persistent juvenile T waves often mistaken for ischemic T waves
Typical features:
-Asymmetric
-Less than 3 mm in depth
-Seen in V1-3. Unusual in V4-6
Concerning differential to consider: anterior ischemia, Brugada, PE, ARVC, RVH w/ strain, RBBB (or incomplete)
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Routine Tn Not Indicated in Syncope
-LOC w/ spont return baseline w/ ACS extremely rare
-PMID: 41201260- Tn w/ poor sens/spec for predicting 30d adverse events(death, dysrhythmia, ACS, PE)
-ECG only routine test. Every other test depends on clinical evaluation
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Pulse Oximeter is THE Best Tool in Resuscitation
1)Gives you O2 sat
2)Gives you HR
3)Gives you marker of peripheral perfusion: poor waveform = poor perfusion = give volume or vasoactives
4)(May) give you perfusion index: quantifiable strength of perfusion
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NTG in SCAPE
-Priorities in SCAPE: Lysis of sympathetic response, pre/afterload reduction
-Aggressive NTG key intervention
-Large bolus: 1-2 mg q3-5 min (PMID: 34215472, 38050078, 17509731)
-Moderate bolus + gtt: 500 - 1000 mcg + gtt @500 mcg/min
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Humeral IOs are fantastic bridges in patients who are peripherally clamped down.
Pearls: Internally rotate the arm to get better access to the humeral head. After placement, avoid external rotation as it results in bending the IO or dislodgment
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Re-Ox w/ Supraglottic Device
-Standard re-ox approach is to use a facemask + BVM
-Problem is that holding a proper mask seal is a skill that can easily degrade under stress
-Solution: re-ox w/ your supraglottic device: no need to hold mask seal + faster re-ox
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most places here have to get it from pharmacy or gets mixed in ED (particularly if you have ED pharmacists
Insulin bolus typically not necessary in DKA but, consider if:
Delay in getting insulin drip from pharamacy.
Severe acidosis: reach therapeutic levels faster + fix the acidosis faster
Bolus dose: 0.1 U/kg
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Urine Drug Screen is useless in ED
-False (+) common due to cross-reactivity
-False (-) common: only looks for THC, cocaine, BZD, amphetamines, pcp + opiates
-Can’t tell you if patient’s symptoms are from the drug
All of this makes the test clinically useless
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HOB 30 degrees not ideal for mech vent in obesity
-Pushes abdominal girth into diaphragm making diffi to deliver breath
-Data (PMID:33432600, 37832782) suggests reverse trendelenberg better position
-If can’t maintain reverse trendelenberg, consider lying flat
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Super interesting topic. I’ve done this and teach it but will have to reconsider
Cannabis + CV Risk
-Regular cannabis use (3x/week) linked to incr risk CAD, stroke, HTN, heart failure + possibly mortality
-Edibles carry same risk
-Regular use a non-traditional ACS risk factor: HIV, CKD, chronic alcoholism, cocaine, lupus
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Femoral Central Lines are awesome!
1) Infection rate equal to rate with IJ (subclavian are cleaner)
2) Easier to place in the awake patient
3) 0% PTX rate (IJ ~ 0.5%, Subclavian ~ 1.5%)
4) Single prep for CVL + Art line
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I use the standing algorithm
Incr safe apneic time increases 1st pass success + safety
-Preox w/ NIV: Incr PaO2, recruits alveoli(PMID: 38869091)
-Preox + intubate w/ Bed Up, Head Elevated(PMID: 26866753)
-Apneic O2 w/ nasal cannula at flush
-Use roc over sux(+45 sec PMID 21226882 + 20402874)
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Avoid crystalloid in hemorrhagic shock
-May incr BP but not O2 carrying
-Dilute Hgb + clotting factors
-Saline contributes to acidosis + cold fluids contribute to hypothermia which worsens clotting
Patients don’t bleed crystalloid so don’t give crystalloid
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Bicarb Pushes
-Na channel blockade on heart: TCA + diphenhydramine toxicity (narrows QRS + stabilizes patient)
-Salicylism: alkalinizes urine incr toxin excretion
-HypoNa w/ seizures or significant neurological dysfunction when hypertonic saline not available
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Thanks for sharing. Definitely interesting but I question if it would be the same in critically ill non-ventilated patients presenting with metabolic acidosis
Regardless, agree that infusion is the bigger chance for a win
Prolonged paralysis w/ rocuronium is an advantage
-Once we decide to intubate, patient's getting tubed
-W/sux, can end up in awake pt while trying to intubate if 1st/2nd attempt fail
-W/ roc, plenty of time if you run into a challenging airway
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Agree with you but, BICARICU2 was infusion not push dose which I think matters
also, dialysis is a bit of a clinician driven thing and this wasn't blinded
regardless, the minimal cost of some bicarb compared to dialysis is a win
Can I suggest getting a cup of coffee instead?
only if you really really really really want to
thanks for sharing. I've got to review in full but issues I see: how was bicarb given (this seems like infusion, not push dose), obviously not an RCT (lots of confounding) and they excluded things like DKA which is odd
No role for bicarb pushes in metabolic acidosis
-Bicarb only incr pH if incr ventilation
-Met acidosis w/ resp alkalosis are maximally ventilating + blowing off CO2
-Intubating unlikely to help
-Bicarb pushes will worsen acidosis if not increasing ventilation
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Observation Post-Epi in Anaphylaxis
-Epi 0.5 mg IM: only critical med in anaphylaxis. If A, B or C, give E
-Biphasic rxn extremely rare: 0.18% (PMID: 24239340) + can occur days out
-I typically observe X 2 hours. Key is to ensure access to epi autoinjector
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