REBEL Cast Ep 46b: Vent Management in the Crashing Patient with Haney Mallemat

12 Mar
March 12, 2018

In Episode 46a we discussed respiratory failure and NIV.  In episode 46b we are going move on to the patient where you have tried NIV and your patient just doesn’t seem to be improving.  You decide to intubate your patient and connect them to the ventilator.  Now the ventilator starts beeping and your patient begins to decompensate.  What are the steps you use to assess the problem and fix it? Read more →

Simplifying Mechanical Ventilation – Part I

08 Mar
March 8, 2018

Mechanical Ventilation is a modality commonly used in the critically ill, but many providers, may not have a strong understanding of the basics. Emergency Medicine and Critical Care Physicians need to have a firm grasp of the basic concepts of mechanical ventilation because without it, we can do serious harm to our patients. Airway management is not complete once the endotracheal tube is placed through the cords, and the proper selection of both the ventilator mode and initial settings is essential to ensure your patient has the best possible outcomes. You should not simply rely on the respiratory therapist to know your patients physiology. Clear communication with your therapist about the patient’s physiology and initial ventilator setting is crucial. Read more →

(Dis)utility of Orthostatics in Volume Depletion

05 Mar
March 5, 2018

Definition: Orthostatic hypotension (OH) is a form of low blood pressure that occurs with positional change (i.e. sitting up from lying down, standing up from sitting). It is commonly used for the diagnosis of volume depletion

Orthostatic Vital Signs

  • A reduction of systolic blood pressure (SBP) of at least 20 mm Hg
  • A reduction in diastolic blood pressure (DBP) of at least 10 mm Hg
  • An increase in heart rate (HR) by > 30 beats per minute

One of the above criteria must be met while measured 3 minutes after standing from a supine position.

Clinical Question: Are orthostatic vital signs useful in finding patients with occult volume loss? Do they add to our standard clinical assessment of patients? Read more →

Milk of Amnesia (Propofol) for Pediatric Migraines?

01 Mar
March 1, 2018

Background: There are several classes of medications available to treat pediatric migraines and because of this many providers have different combinations that they like to use.  Typically, NSAIDs, anticholinergics, and dopamine antagonists are used with varying degrees of success.  There is little evidence to guide providers if these agents fail in terms of which medications would be helpful for further abortive therapy.  There have been several trials published in the adult population regarding the use of low dose propofol (LDP) for acute migraines.  Propofol is great in the ED setting due to its short acting duration of action, as well as its anti-emetic properties.  Many things done in pediatrics are extrapolated from adult literature, however the authors of this paper wanted to see if LDP was any better than standard therapy (ST) in the treatment of acute pediatric migraines. Read more →

Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over?

28 Feb
February 28, 2018

Background:  Normal Saline (NS) is one of the most commonly used IVFs in resuscitation today.  The use of balanced vs unbalanced crystalloids has been one of the biggest debates in resuscitation of the critically ill in recent history due to concerns of unbalanced fluids causing acute kidney injury, hyperchloremic metabolic acidosis,  and worsened mortality.  In 2015, we saw the publication of the SPLIT trial, which we covered on REBEL EM. This was a randomized clinical trial of over 2200 patients in 4 ICUs in New Zealand comparing 0.9% Saline (NS) vs Plasma-Lyte.  This trial had many issues including, >70% of patients coming from the OR, only 15% came from the ED, only 4% had sepsis, and the biggest issue with this trial was that the majority of patients only received 1 – 2L of NS, making it unclear if larger volumes of unbalanced crystalloid would have worsened morbidity and mortality.  Since the publication of this study, two more trials have been published: The SALT-ED Trial and The SMART trial (Both Just published in the NEJM Feb 27th, 2018). Read more →

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