September 19, 2019

Shock is defined as circulatory failure leading to decreased organ perfusion.  In a shock state there is an inadequate delivery of oxygenated blood to tissues that results in end-organ dysfunction.  Effective resuscitation includes rapid identification and correction of inadequate circulation.  the finding of normal hemodynamic parameters (i.e. normal blood pressure) doe not exclude shock itself.  In this 11 minute and 40 second video, I will review the management shock - part 1 (The goals of shock management, signs of adequate organ perfusion, the etiology of shock, and some basic terminology).

September 16, 2019

Background: Rapid sequence intubation (RSI) involves the use of an induction agent followed by a neuromuscular blocking (NMB) agent to obtain optimal intubating conditions.  Administration of a NMB results in apnea which, in turn, can lead to oxygen desaturation.  Oxygen desaturation during rapid sequence intubation may lead to serious adverse events including dysrhythmias, hypotension, and cardiac arrest.  Preoxygenation helps extend the duration of safe apnea and has 2 major goals:
  1. Attempt to achieve an O2 saturation of 100%
  2. Maximize oxygen storage in the lungs by denitrogenation of the residual capacity of the lungs (Approximately 95% of oxygen reservoir)
Preoxygenation is assessed in the ED but usually through pulse oximetry which is inadequate.  In the operating room, anesthesiolgists use gas analyzers to quantify and optimize preoxygenation with ETO2.  In critically ill patients, preoxygenation should be performed to achieve an ETO2 ≥85% based on the response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society [2].

September 12, 2019

Background:

  • Tramadol is a centrally acting synthetic opioid analgesic approved for use in the United States in 1995 by the Food and Drug Administration.
  • In 2014, the Drug Enforcement Agency classified tramadol as a Schedule IV controlled substance.
  • ~41 million prescriptions for tramadol were dispensed in the United States in 2017.

September 11, 2019

Take Home Points:

  • Get definitive airway control when necessary
    • Use modality you’re most comfortable with
  • Hard signs -  pulsatile bleeding, bruit or thrill, expanding hematoma, airway compromise, massive hemoptysis (think airway injury), hematemesis (think esophageal injury), grossly injured trachea, neurologic deficit, subcutaneous emphysema.
  • Soft Signs are hypotension that resolves, stable hematoma, wound in proximity to major vascular structure, minor hemoptysis, dyspnea, dysphagia, chest tube air leak, vascular bruit or thrill (depends on surgeon).
  • Hard Sign on presentation goes straight to the OR. Soft Sign on presentation gets some imaging done
  • Resuscitate with blood products -> Activate massive transfusion protocol
  • Most hemorrhage will respond to direct pressure
  • Don't miss other injuries!

September 9, 2019

Background: Epinephrine (adrenaline) has been used in advanced life support in cardiac arrest since the early 1960s. Despite the routine recommendation for its use, evidence to support administration is less than ideal.  Although it is clear from multiple observational studies that epinephrine improves return of spontaneous circulation (ROSC) and short-term survival, most evidence suggests an absence of improvements in survival with good neurologic outcomes.  In cardiac arrest we want to take advantage of the alpha effects of epinephrine, including peripheral vasoconstriction, and therefore increasing aortic diastolic pressure, which in turn helps augment coronary and cerebral blood flow.  On the other hand, we want to avoid the potentially detrimental beta effects including dysrhythmias, decreased microcirculation, and increased myocardial oxygen demand all of which increase the chances of recurrent cardiac arrest and decreased neurologic recovery.  The only two interventions in cardiac arrest that have shown improve survival with good neurologic outcomes continue to be high-quality CPR and early defibrillation. The debate over the utility of epinephrine in OHCA has been ongoing for several years now and many providers are left with the ultimate question of what to do with epinephrine in OHCA.