I just wanted to remind you that the term "institutional loyalty" refers to you being loyal to your institution (hospital), not the institution being loyal to you. You are dispensable...
#medsky
“There are three stages of scientific discovery: first people deny it is true; then they deny it is important; finally they credit the wrong person”
- Alexander von Humboldt (1769–1859)
ICU Snapshots:
This is what I don't want to see when a patient on heparin drip crashes:
ICU - Board Review Qs:
60 yo pt admitted to the ICU because of inferior STEMI. Emergency cath: 100% proximal RCA occlusion treated successfully with stenting
One hour post-PCI: dyspnea/anxiety - BP: 94/70, HR: 60/min (sinus). Phys exam: JVD (+), clear lungs, cool extremities
I consider Emergency Medicine the most difficult specialty. That said, in a non-mass casualty ED situation, sending to the ICU a septic patient, hypotensive on 2 pressors, anuric, hypoxic, with a Hb of 5.0, lactate 10.0 & K 6.0, w an IO & a non-functioning 22g may be less than ideal
ICU/ED Airway "Secrets":
~40% of endotracheal intubations (ETI) performed in the ICU or the ED result in hypotension, hypoxemia, or cardiac arrest
Of all procedures, ETI is the one I find most intimidating & have the greatest respect for
#foamed #foamcc #meded #medsky #emimcc
ICU Secrets:
If you use the Swan-Ganz catheter as a long central venous catheter, such as monitoring only the CVP value, then chances are that you won’t become much wiser by inserting it…
#foamcc #hemodynamics #emimcc
ICU/ED/OR Airway "Secrets":
#foamed #foamcc #meded #medsky #emimcc #airways
While you attempt direct laryngoscopy in a hypoxemic patient, you get this view:
ICU Stories (at the beginning of my night shift):
Me: Anybody coming?
Morning ICU shift attending: Just a young patient with etoh withdrawal from 2D
The patient 👇:
Not responsive. SBP in the 80s, HR: 150/min, breathing 60/min. O2 sat 96% on 15 l/m non-rebreather mask. Febrile
From:
Current Anesthesiology Reports (2024) 14: 446-57. doi.org/10.1007/s401...
Just one of the personalized peri-intubation resuscitation approaches:
Always "fun" to intubate these patients. There is NO room for error. Hypoxic, hypotensive, altered... What can go wrong in this physiologically scary airway? I find it extremely hard to do "awake" intubation in this scenario...
Miraculously the patient did not arrest on induction
The shock index (SI), calculated as HR/SBP, predicts post-intubation hypotension (PIH) & cardiovascular collapse. A pre-intubation SI >0.8-0.9 suggests ⬆️ risk of PIH. In this case, SI was around 2.0 & SBP was 80 with patient already on norepi 0.3 (started from a peripheral iv upon ICU arrival)
ICU Stories (at the beginning of my night shift):
Me: Anybody coming?
Morning ICU shift attending: Just a young patient with etoh withdrawal from 2D
The patient 👇:
Not responsive. SBP in the 80s, HR: 150/min, breathing 60/min. O2 sat 96% on 15 l/m non-rebreather mask. Febrile
Thanks for following!
1. Case taken from: DOI 10.1007/s12630-016-0804-x
2. 5minuteairway.com/2016/12/19/c...
3. pemplaybook.org/podcast/airw...
4. drsanu.com/articles/lar...
This is why seeing the endotracheal tube passing through the vocal cords is not the ‘‘gold standard" that we think it is & we have to confirm its placement with other means (waveform capnography)
If you chose grade 1 CL or POGO >90%, you need to make sure that you were actually looking at the glottis...
In this case, the esophageal opening (E) can be confused
with the normal glottic opening (G), thus impersonating it:
The POGO score represents the percentage of glottic opening seen, as defined by the linear span from the anterior commissure to the inter-arytenoid notch. A POGO score of 100% is a full view of the glottis & corresponds to the best CL grade 1 view:
The Cormack-Lehane grading system for laryngeal exposure was first described in 1984 for obstetric anesthesia. The original CL grading system consisted of 4 grades:
What is the POGO (Percentage of Glottic Opening) score?
<10%
50%
75%
>90%
What is the Cormack-Lehane (CL) grading for this view?
Grade 1
Grade 2
Grade 3
Grade 4
ICU/ED/OR Airway "Secrets":
#foamed #foamcc #meded #medsky #emimcc #airways
While you attempt direct laryngoscopy in a hypoxemic patient, you get this view:
I consider Emergency Medicine the most difficult specialty. That said, in a non-mass casualty ED situation, sending to the ICU a septic patient, hypotensive on 2 pressors, anuric, hypoxic, with a Hb of 5.0, lactate 10.0 & K 6.0, w an IO & a non-functioning 22g may be less than ideal
ICU/ED Airway "Secrets":
~40% of endotracheal intubations (ETI) performed in the ICU or the ED result in hypotension, hypoxemia, or cardiac arrest
Of all procedures, ETI is the one I find most intimidating & have the greatest respect for
#foamed #foamcc #meded #medsky #emimcc
No PICCO here... It's a European toy...
“Large language models can be unreliable and say dumb things, but then, so can humans”
-Blaise Agüera y Arcas
Most (>80%) spontaneous RP bleeds are venous. In this case, CT angio revealed active extravasation. Despite emergent embolization, patient did not survive...
#foamed #foamcc #meded #medsky #emimcc #heparin
Or the areas of active extravasation?
Huge retroperitoneal bleed (RPB)... Did you notice the left kidney (LK) being displaced to the midline?
ICU Snapshots:
This is what I don't want to see when a patient on heparin drip crashes:
