Category: Critical Care

Podcast #205: Post Cardiac Arrest Temperature Control

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Author: Michael Hunt, M.D.

Educational Pearls:

  • Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes.
  • Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels.
  • New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests.   The results show that it may not be necessary to cool inpatient cardiac arrests.

References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

 

Podcast #204: Thoracotomy

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Author: Aaron Lessen M.D.

Educational Pearls:

 

  • Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
  • Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
  • Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
  • A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

 

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

 

Podcast #194: Atruamatic ICH

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Author: Peter Bakes, M.D

Educational Pearls

  • Intracerebral hemorrhage is an intracranial bleed within the brain tissue or ventricles.
  • Subarachnoid aneurysm causes about 50% of all ICH.
  • Amyloid deposition can lead to ICH in elderly patients.
  • Hypertension is another common cause of atraumatic ICH, commonly leading to pontine, cerebellar, or basal ganglial bleeding. Bleeding in other locations is suggestive of a different etiology.
  • ICH will often present with depressed mental status, but specifically a patient with a systolic BP > 220 is suggestive of hypertensive ICH.
  • CT is the first diagnostic step. CTA should be considered when the bleeding is in an atypical area. Significant edema on imaging can be suggestive of a tumor.
  • Treatment should include hemostatic measures and BP control. Transfuse platelets if necessary and reverse any anticoagulation. BP target is <140 systolic. Monitor ICP if patient has AMS. Neurosurgical intervention is indicated when there is significant expansion of the hematoma with AMS or if the bleed is cerebellar.

References: Sahni R, Weinberger J. Management of intracerebral hemorrhage. Vascular Health and Risk Management. 2007;3(5):701-709. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2291314/

Podcast #181: Electrolyte Emergency

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Run Time: 5 minutes

Author: Peter Bakes, MD

Educational Pearls:

  • Calcium is ubiquitous ion in the body necessary for bone, muscle, and nerve function
  • Hypocalcemia is associated with tetany (elicit Chvostek’s sign and Trousseau’s sign) and irritability
  • Hypocalcemia can progress to seizures and prolonged QT which can cause cardiac arrest
  • Hypocalcemia can be caused by vitamin D deficiency
  • Patients with malabsorption are at risk of vitamin deficiencies

Link to Podcast: http://medicalminute.madewithopinion.com/electrolyte-emergency/

References: http://emedicine.medscape.com/article/241893-overview

http://www.mayoclinic.org/diseases-conditions/short-bowel-syndrome/basics/definition/con-20037215

Podcast #180: Aortic Dissection

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a_dissectionRun Time:  4 minutes

Author: Jared Scott, MD

Educational Pearls:

  • Aortic dissection = separation between 2 layers of vessel wall (usually intima and media)
  • Aortic Aneurysm = cystic dilation of the aorta
  • Aortic dissection associated with severe HTN or connective tissue disorders (Marfan’s, Ehlers-Danlos, etc.)
  • AAA associated with HTN, DM, HLD, smoking (same risks for MI)
  • Aortic dissection starts proximal in chest and peels down
  • AAA confined to abdomen and can rupture. 90% mortality.

Link to Podcast: http://medicalminute.madewithopinion.com/aortic-dissection/

References: http://www.mayoclinic.org/diseases-conditions/aortic-dissection/basics/definition/con-20032930

Podcast #173: Defibrillation

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1ec59cb3-e6f4-4dd6-be56-c456e55d0a49Run Time:  3 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Defibrillation is used to depolarize the heart and reset the electrical activity. How can the success of defibrillation be maximized for a patient with persistent Vfib and has been shocked several times previously by EMS.  
  • Success is dependent on the contact of the pads with the chest. Drying off a patient, removing hair and increasing pressure can all improve success, but so can dual sequential defibrillation.
  • Dual sequential defibrillation is the use of 2 simultaneous defibrillators to increases the amount of electricity reaching the heart.
  • One set of pads from each defibrillator are placed in the AP lateral position and the other set of pads are placed in the AP posterior position.
  • This is generally considered a safe technique to increase the electricity to the heart and the chances of success of defibrillation.

Link to Podcast: http://medicalminute.madewithopinion.com/defibrillation/

References: http://www.sciencedirect.com/science/article/pii/0735109794906025

Podcast #172: CPSSS

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fc67e872-002b-4713-931e-7f8a76b41e3cRun Time:  3 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • The most recent data on value on interventional neuroradiology suggests that the patients who receive the most benefit from neuroradiology are those with a large vessel occlusion, and can have up to 50% reduction in mortality.
  • The question is for EMS, when should you bypass other hospitals to go directly to a comprehensive stroke center with neuroradiology.
  • The CPSSS – Cincinnati prehospital stroke severity score – is an augmentation of the Cincinnati prehospital stroke scale to help identify a large vessel occlusion.
  • CPSSS is a 4 point score: 2 – eye deviation, 1- abnormal LOC, 1 – arm drift.
  • A score of 2 or more is 80% sensitivity for a large vessel occlusion. However the specificity is not of this scale is not as good.
  • There is a large push to standardize the CPSSS to allow EMS to bypass other hospitals in order to get to comprehensive stroke center.

Link to Podcast: http://medicalminute.madewithopinion.com/cpsss/

References: http://stroke.ahajournals.org/content/46/6/1508.short

http://jnis.bmj.com/content/early/2016/02/17/neurintsurg-2015-012131.full.pdf

Podcast #165: TTP

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fafc49c3-5bf2-4289-bf57-a58c8cfd5ac6Run Time: 5 minutes

Author: Eric Miller M.D.

Educational Pearls:

  • TTP stands for thrombotic thrombocytopenic purpura.
  • TTP patients usually have renal failure, bruising or petechia, anemia, confusion, and other neurologic changes, which distinguishes itself from ITP which is mostly characterized by just low platelets and petechia.
  • Both TTP and ITP are thought to be autoimmune diseases where the body produces antibodies that attack your own platelets or blood clotting mechanisms, preventing blood from clotting. In the case of TTP – antibodies attack a protein called ADAM TS-13, which cleaves Von Willibrand Factor.
  • Without treatment TTP has a 95% mortality rate, but with treatment patients have a 5-10% mortality rate.
  • Patients with TTP are admitted to the ICU and receive complete plasma transfusions daily – which takes out the antibodies that prevent clotting, dialysis for kidney failure, and steroids – because the majority of autoimmune diseases respond to steroids.
  • Causes of TTP can be infectious, chemotherapy, or common medications. However, only about 4 out of 1 million people get TTP yearly.
  • Pediatric patients who have hemolytic uremic syndrome have similar symptoms, and usually have a bacterial gastorintestinal infection from E.coli or Shigella toxin.

Link to Podcast: http://medicalminute.madewithopinion.com/ttp/

References: https://www.nhlbi.nih.gov/health/health-topics/topics/ttp

Podcast #162: Jaw Infections

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1e060aa3-b451-45a8-9b7c-7ff5fc99ee60Run Time:  3 minutes

Author: Suzanne Chilton M.D.

Educational Pearls:

  • Patient presentation: 2 weeks of mouth pain, no recent dentist visit, low grade fever, and muffled or hot potato voice.
  • Patient exam: swollen tongue that is located up and back in the mouth, edema under tongue, diffuse erythema, and rancid breath.
  • This patient has Ludwig’s Angina – a potentially life-threatening cellulitis of the lower jaw space.
  • The infection starts from a dental infection – most commonly between the 2nd & 3rd molar because roots of these teeth go into a space between the muscles of the head and neck that can reach down to the anterior neck.
  • The most serious complication for patients is maintaining their airway. Patients should be placed in a room with advanced airway management and a cricothyrotomy kit near by.
  • Treatment is broad spectrum antibiotics that targets anaerobes, and oral flora such as clindamycin or unasyn with flagyl.
  • Steroids will help with the swelling – patients have a 65% less chance of intubation if they are given steroids.

Link to Podcast: http://medicalminute.madewithopinion.com/jaw-infections/

References: http://www.ncbi.nlm.nih.gov/pubmed/18952475

Podcast #150: Platelet Transfusion

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f0d0df7e-0c53-4ced-9581-6cae44786067Run Time: 2 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • For years it has been a widely accepted policy to give platelet transfusions to patients with ICH regardless of their antiplatelet medication history, but is it necessary?
  • A study in Holland – Dylan’s people – looked at the effects of platelet transfusion in patients on antiplatelet drugs admitted for an ICH.
  • The randomized trial evaluated standard care vs. standard care with platelet transfusion for ICH patients, not in a coma, who had taken an antiplatelet drug within the last week.
  • If  patients received platelets they had twice the risk of adverse events while in the hospital – MI, thrombotic events, allergic reaction, etc. So maybe platelets have more harm than benefit in this pt population.

Link to Podcast: http://medicalminute.madewithopinion.com/platelet-transfusion/

References: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)30392-0.pdf