The pt is a 70 yo M who presents with AMS, weakness and nausea for 1-2 days. He complains of diffuse weakness and feeling "sick". His hx is significant for HTN, HLD, CHF and he takes digoxin. Vital signs on arrival are BP 90/60 with HR 47. There is concern for digoxin toxicity, so dig level is obtained and is 2.4
(normal is less than 1.2).
His K is 6 and Cr is 1.9. EKG shows LBBB.
Read MoreWhy Should You Care?
If you were to choose one vital sign for your critically ill patient, what would you choose? Blood pressure? Pulse? Respiratory rate? O2 sat? Temperature? Certainly it’s nice to know if a patient’s BP is super low or sky high, but if you are evaluating someone for the presence of shock, and you are waiting on the BP cuff to cycle one more time, you are already behind in recognizing and correcting the patient’s physiologic derangements.
Read MoreEmergency airway management is being revolutionized. Think about it…those of us who are in training now are being exposed to some very different core skills. The big culprit is the recent advent of video laryngoscopy – not much argument there.
With that said, I will argue that almost as significant as the advent of video laryngoscopy from a general “airway management revolution” perspective is the philosophical change of many pre-hospital providers in that it is becoming the norm for extra-glottic devices to be placed primarily, or at least considerably more often than in the past.
It is likely that the rate of field placement of extra-glottic devices will become more common. Thus, we will probably see many more patients present to the ED in whom EMS has placed an extra-glottic. As we recognize the power of extra-glottic devices, I think that even the most advanced airway managers will use extra-glottic devices with more frequency to facilitate rescue oxygenation and ventilation.
This begs the obvious question: should we remove these devices after they are in and working?
Read MoreVentilator management can be one of the more intimidating aspects of caring for critically ill patients both in the ED and in the prehospital setting. There are several great #FOAMed resources out there on varying aspects of ventilator management including the well-known series by Dr. Weingart of emcrit.org (here and here). Ventilator management can be an absolutely massive topic but for this post, and specifically for the embedded video below, I wanted to do a little deeper dive on only one of the components of ventilatory management: PEEP.
Read MoreNext 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.
Read MoreIn March of 2014, Derek Angus and colleagues published the ProCESS trail in the NEJM (1)(N Engl J Med 2014;370:1683-93. DOI: 10.1056/NEJMoa1401602). In ProCESS, they explore the time-honored theory in EM-resuscitation that EGDT as described by Rivers (NEJM 2001) is the dominant strategy to improve survival in severe sepsis and septic shock. Despite the marked reduction in mortality that is reported in Rivers’ study, the study itself has not been successfully reproduced in a multicenter trial.
Read MoreWe fly/transfer many patients with STEMI on Air Care and Mobile Care. And, fortunately, a majority of these patients end up doing very well. You accept them at the referring facility, load them in the helicopter, and transfer them to the cath lab at the receiving facility without incident. You certainly may make some adjustments in nitro drips, maybe give some metoprolol, certainly review their outside hospital records, but usually the biggest benefit you are offering them is rapidity of transport. Transport 20 or 30 of these patients without incident and you might get lulled into thinking that these patients are so incredibly stable that nothing bad will happen during the course of the transport. To do so would be folly.
Read MoreHow many hands does it take to run a code? Think about that for a bit...
In the SRU, the available hands seem essentially limitless. There's a train of PCAs and medical students lined up to perform CPR, a nurse to run the monitor and defib, a nurse and/or pharmacist pulling up meds and mixing drips, a nurse charting, a MD dedicated to the airway, a RT to help with bagging, not to mention the MD running the whole show. At a minimum you probably have 10 hands ready to ensure compressions are as uninterrupted as possible, to keep a check on the respiratory rate, to hook up monitors, push meds, defib, and all the other tasks that are necessary to code a patient.
Now what do you do in the back of the helicopter when a patient loses a pulse?
Read MoreOf the injuries that one will care for in the pre-hospital setting, traumatic brain injury is one of the most challenging. Quite often, more than one organ system has been injured and they require rapid, thoughtful, and precise management of their airway and hemodynamics. In addition, TBI patients require frequent reassessment to detect progression of the primary neurologic injury. This is easier said than done in the dynamic, unpredictable, and resource-limited prehospital environment.
To help simplify their care, the following “Code of Care” forms the core principles that characterize optimal TBI care:
Close your eyes... actually open them up, you won't be able to read the description if you close your eyes... Imagine you are on flying on the helicopter for a scene flight. You land and are brought to the patient, a victim of a motorcycle accident who is clearly in need of an airway. He is obtunded with sonorous respirations, a GCS of 6, O2 sats in the low 90's. You start to look and assess the patient's airway and you are decidedly less than pleased.
Read MoreExtraglottic devices are often term "rescue devices." And I can't decide whether this is a term that glorifies or degrades. While yes they can often save your tail after a failed attempt at direct or video laryngoscopy, they can do so much more. Running a code in a resource limited setting with 2 providers? The gold standard of 2 person bag valve mask technique ain't going to be an option for you. And you think you can hold C-E mask seal while bagging for 20 min? If you can, you must have hands that rival the late great Andre Rene Roussimoff...
Read MoreIn emergency medicine, EMS, and critical care transport medicine, I think we’d all (at least secretly) agree that there’s absolutely no greater joy than being able to say to ourselves, “That guy (or lady) is still walking the earth because of the care my team and I were able to give him (or her).” I’m talking about the sort of patient that you bring back from the very brink of death with knowledge and skill borne of hard work and practice.
Read MoreSRU (pronounced "shrew") = Shock Resuscitation Unit
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
Training in, and managing, the SRU is one of the crown jewels of our residency. It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.
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