Author Archive for: robbryant13

Pediatric Push Dose Epinephrine: Getting the Epi Dose Right During Pediatric Resuscitation

13 Sep
September 13, 2018

Warning: Limited Published Evidence on this Topic

You have just intubated a 4 year old with sepsis from a bad pneumonia. Post intubation BP is 70 systolic, while waiting for the epinephrine (adrenaline) infusion to come up from pharmacy you watch the BP decline into the 60 systolic range and start to use fluids to resuscitate. You are an accomplished adult resuscitationist, and are comfortable mixing, and pushing push dose epi in your adult patients.

The following questions arise as you consider mixing a batch of push dose epi:

  • How much push dose epinephrine should you give this septic 4 year old?
  • Do pediatric patients need more or less epi when given in push dose format?
  • How do some pediatric intensivists and pediatric emergency physicians manage this problem?

Read more →

BICAR-ICU: How Should this Study Affect Care in the ED?

10 Sep
September 10, 2018

During a busy resuscitation it behooves the ED resuscitationist to avoid ordering therapies that have no clear benefit to their patients. Our nurses are overburdened, and adding interventions ‘just to be safe’ or ‘because we always do it’ is a great way to overwhelm our nursing colleagues. Bicarb administration is a contentious issue and many clinicians consider its use to fall firmly into the no-benefit camp, even when used in the management of severe metabolic acidosis. There have been no studies to date evaluating clinical outcomes  with the use of  sodium bicarbonate infusion therapy for severe metabolic acidemia, until now.  This post is a review of the recently published BICAR-ICU trial Read more →

Abscess Management: The Reformation of an Antibiotic Nihilist

12 May
May 12, 2018

Abscess management has evolved somewhat in the 14 years since my residency graduation. The point at which antibiotics are likely to be more helpful than harmful is not always easy to assess, and evidence based expert opinion has flip flopped impressively.

Based on current evidence, I would like to answer 3 big questions that every clinician may have when confronted with an abscess:

  1. Who needs antibiotics?
  2. Which abscesses need to be drained?
  3. How should abscesses be drained?

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Peri-Intubation Anaphylaxis

08 May
May 8, 2017

Background: Peri-operative anaphylaxis is an unexpected complication of intubation. The major life threat in anaphylaxis is typically loss of airway, however profound hypotension and circulatory collapse are still possible life threats even in the setting of a protected airway. Peri-operative anaphylaxis is considered an important enough issue to be the subject of the NAP 6 (National Audit Project) audit this year in Great Britain.  (Reporting period November 2015 – November 2016). Read more →

Post Intubation Hypotension: The AH SHITE mnemonic

20 Apr
April 20, 2017

You have just secured the endotracheal tube following an uneventful intubation of a moderately ill  patient in your emergency department. They had a normal pre-intubation blood pressure.  As you are calling the admit in to the ICU the patient’s nurse tells you that the BP is now in the 70’s.

NOW WHAT?

  1. Blindly give a half gallon of saline and stay in your seat.
  2. Get up, walk to the patient’s room, and consider the possible causes of post intubation hypotension.

Read more →