Grand Rounds Recap 7.12.23

/

fundamentals of ecmo WITH dr. bonomo

ECPR from the ED:

The ideal patients:

  • Young patients with refractory VF/VT arrest ≤ 30 min since arrest onset

  • Poisonings with cardiogenic shock

  • Severe hypothermia with arrest

  • Massive PE with arrest

Key points:

  • Good CPR/advanced ACLS

  • LUCAS

  • Initial rhythm identification

  • Epinephrine drip

  • Speed to cath lab

Pre-procedural checklist (must meet all inclusion criteria):

  • No asystole

  • Lactate < 15

  • ETCO2 ≥ 10 mmHg

  • PaO2 ≥ 50 mmHg

  • Adequate access

  • Willing to take blood products

  • Any size limitations

VV-ECMO in ED:

  • Data shows majority of patients referred for VV-ECMO may not need it

  • Can’t oxygenate, can’t ventilate despite maximal ventilator settings

    • PEEP>10

    • Fio2=100

    • Post-recruitment

    • ARDS-type CXR or massive PE

leadership curriculum: Listening like a leader WITH dr. mcdonough

Why seek first to understand?

  • Make speakers more relaxed

  • Make speakers more self-aware

  • Help speakers gain clarity and reflect non-defensively

  • Help speakers see both sides of an argument

  • Perceived as “people leaders”

  • Generate more trust

  • Instill higher job satisfaction

  • Increase team creativity

How to be a better listener?

Sampled from “The 7 Habits of Highly Effective People” by Stephen R. Covey

  1. For planned conversations, be intentional about time and location

  2. Use your body language to show you are paying attention

  3. Don’t interrupt with your own thoughts and solutions

  4. Encourage the speaker to finish their thought

  5. Paraphrase back what you’ve heard to make sure you understand correctly

  6. Respond to unspoken messages conveyed through tone and body language

  7. Validate people’s feelings in ways that you show you understand them

  8. Listen with an ear for how people’s ideas and opinions overlap and diverge

  9. Use open-ended questions to expand people’s thinking on an issue

ultrasound grand rounds: ARTifact artifiction WITH dr. stolz

  • Artifact: a false portrayal of image anatomy or image degradations related to false assumptions regarding the propagation and interaction of ultrasound with tissues

  • Acoustic shadowing: an ultrasound imaging artifact occurring at boundaries between different tissue impedance, resulting in signal loss of a dark appearance 

  • Dirty shadow:

    • Echogenic line in near field

    • Gray shadow

    • Isoechoic/mixed shadow

    • Scattered sound

    • Air

  • Clean shadow:

    • Echogenic line in near field

    • Black shadow

    • Anechoic shadow

    • Reflected sound

    • Bone/stone

  • Posterior acoustic enhancement: a different type of shadow enhanced through transmission; increased echoes deep to structures that transmit sound exceptionally well

  • Edge artifact: a refraction artifact; the ultrasound beam refracts at a tissue boundary

    • Caused by a speed of sound difference and a change in wavelength

  • Mirror image artifact: caused by ultrasound waves reflecting off a highly reflective surface then taking an indirect path back to the ultrasound probe

  • Reverberation artifact: when ultrasound is reflected between two parallel reflective surfaces lying perpendicular to its path; some pulses bounce forwards and backwards between the two surfaces before returning to the probe

  • Anisotropy: when ultrasound waves hit a highly reflective fibrillar structure at an angle, the waves are reflected away from the transducer; the area is interpreted as “dark” because no waves are reflected back to the probe

  • Aliasing: under-sampling artifact

    • When blood is moving faster than the ultrasound machine’s ability to detect the speed, it will show it traveling it the wrong direction

  • Twinkle artifact: when ultrasound waves interface with a strong, granular, irregular reflector and a color Doppler pattern of rapid alternations of blue and red is seen

macgyver techniques: central line microskills WITH dr. ham

image 1. optimal room set-up

Room Set-up:

  • Make the room work for you: trash can propped open, sharps bin nearby

  • Use blue towels underneath the provided drape to create appropriately sized work space and maximize your sterile technique

  • Move bed out to an angle to give yourself space to work

  • Throw out what you don’t need: make your equipment set-up optimized for what you are actually going to use

patient set-up:

  • Consider performing a cervical plexus block for total anesthesia over the side of the neck, especially in patients you anticipate may have trouble staying still or tolerating the procedure

  • Optimize patient positioning: secure the head (tape vs soft restraint)

image 2. optimal equipment set-up

line tips:

  • If you ever need to pause with your wire still in the lumen of the line, use hemostats to clamp the wire to the line and to the drape

  • If you have a very collapsable vessel, consider using the needle with overlying angiocath to access the vessel and provide a flexible placeholder inside the flimsy vessel to allow for passage of wire and completion of line

the final touches:

  • Start at 18cm for all lines: you can always pull the line back, but you can’t advance

  • Ultrasound for confirmation: consider checking additionally for pneumothorax with lung sliding; additionally, using the phased array probe can demonstrate the line in the right atrium if it is truly central