Grand Rounds Recap 9.21.2016

Grand Rounds Recap 9.21.2016

This week we learned about all the hardware that can go into our patient's CNS and how it can go wrong. We also heard about complications of Varicella infection, set out to optimize visualization of a needle on US, learned to give better feedback to the difficult learner, heard about ED super-utilizers and strategized about ventilator management. 

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Grand Rounds Recap 2/3/16

Grand Rounds Recap 2/3/16

This week we had our annual Critical Care Symposium where we invited our own critical care trained faculty and a special guest to have a day chock full of critical care goodness.

Refractory septic shock with Dr. David norton

Dr. David Norton, Assistant Professor of Medicine and Director of the UCMC Medical Intensive Care Unit

Definition of Refractory Shock:

No clear definition exists, but we are generally describing a state of decreased vascular responsiveness despite high vasopressor infusion.

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Ventilator Management Simulation Debriefing

Ventilator Management Simulation Debriefing

Case 1 - "Bucking the Vent"

You have inherited a patient in the VA MICU at signout.  The patient presented with spontaneous bacterial peritonitis and altered mental status and was intubated for airway protection and hypoxic/hypercarbic respiratory failure.  The patient’s altered mental status has resolved but the patient remains intubated waiting for a second large-volume paracentesis that can’t be done over the long weekend at the VA. The RT calls you asking for a one time dose of 5mg Versed, but on a quick glance at the chart, the patient has been getting these Q2 hours for the last several days.  You go to the bedside and find an agitated patient motioning to take out the tube.  “He’s bucking the vent doc!”

Vent settings: AC-VC: TV500  RR12  PEEP8  FiO2 30%

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Grand Rounds Recap - 3/18/15

Grand Rounds Recap - 3/18/15

Evidence-Based Emergency Medicine: Vent Management with Drs. Axelson & Scupp

The term Acute Lung Injury (ALI) is being phased out and instead Acute Respiratory Distress Syndrome (ARDS) is now graded mild, moderate, and severe depending on the PaO2:FiO2 ratio

The median onset of ARDS after presentation to the ED was 2 day but could be anywhere from 5 hours to 5 days

ARDS Net was a foundational trial in ventilator management and was a triall of tidal volume and plateau pressures.  The primary end point, mortality, was reduced by >20% when folks were on a low TV (6cc/kg) and lower PP (25-30 mm Hg).

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Sepsis in the Air

Sepsis in the Air

Next to STEMI and neurologic emergencies such as spontaneous ICH, SAH, and ischemic stroke, one of the most common pathologies we transfer from one facility to another on Air Care is sepsis.  However, unlike many of the other patients we transfer, these patient’s are usually being transferred from the ICU of an outlying facility to the ICU of a tertiary referral center that can deliver a higher intensity of care.  I sat down and discussed with Dr. Bill Knight, a former flight MD and now Emergency Medicine and Neurocritical care physician, about some of the complexities of caring for these patients.

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