Podcast #279: Sedation After Intubation

Author: Aaron Lessen, M.D.

Educational Pearls

  • Post-intubation care should always include pain control and adequate sedation.
  • Commonly used sedation agents include propofol, ketamine and versed.
  • However, too much sedation is harmful. Deep sedation (RASS -4 to -5)  is associated with worse long-term outcomes. RASS of 0 to -2 is ideal, as long as the patient is comfortable.

References: https://coreem.net/core/post-intubation/

Podcast #274: Pediatric Sedation

Author: Aaron Lessen, M.D.

Educational Pearls

  • A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
  • This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
  • Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
  • Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Podcast #272: More on Temperature in Sepsis

Author: David Rosenberg, M.D.

Educational Pearls

  • A study of 20,000 subjects found that reducing fever in sepsis did not improve outcomes such as morbidity, mortality, or length of stay.
  • However, correcting fever may help for patient comfort.

References: Zhang Z, Chen L, Ni H. Antipyretic Therapy in Critically Ill Patients with Sepsis: An Interaction with Body Temperature. Azevedo LCP, ed. PLoS ONE. 2015;10(3):e0121919. doi:10.1371/journal.pone.0121919.

Podcast #268: Poiseuille’s Law

Author:  Dave Rosenberg, M.D.

Educational Pearls

  • Poiseuille’s Law addresses the flow of a fluid through a tube.
  • Many common ED presentations involve alterations in flow: asthma, MI, ischemic stroke, etc.
  • According to the law, flow increases with the 4th power of the radius. That is to say, doubling the radius of the tube will increase the flow by 16x.
  • Therefore, in situations that require re-opening of an anatomic tube (artery, airway), small changes in the size of the opening will result in dramatic effects.

References: https://www.openanesthesia.org/poiseuilles_law_iv_fluids/

Podcast #267: Causes of Very High Lactate

Author: Dylan Luyten, M.D.

Educational Pearls

  • Lactate is a byproduct of anaerobic metabolism, a sign of dying tissue. Dangerous causes of high lactates will not normalize with repeat labs.
  • Crush injuries, seizures, bowel necrosis,  end-stage liver disease, and metformin toxicity are common causes of highly elevated lactate.

References: https://lifeinthefastlane.com/ccc/lactic-acidosis/

Podcast #266: MI in Young Patients

Author: John Winkler, M.D.

Educational Pearls

  • Some risk factors for MI in the young are history of CAD, stimulant drug use, coronary spasm and diabetes.
  • In those with diffuse ST elevations on EKG, think pericarditis. Troponin will also be elevated.

References: Egred M, Viswanathan G, Davis GK Myocardial infarction in young adults Postgraduate Medical Journal 2005;81:741-745

Podcast #264: Witnessed Cardiac Arrest

Author: Aaron Lessen, M.D.

Educational Pearls

  • For patients with in-hospital cardiac arrest, intubation in the 1st 15 minutes of resuscitation was associated with worse outcomes (mortality, neurologic outcome). This is likely due to cessation of high-quality CPR and defibrillation during the intubation sequence.
  • In those with an in-hospital, shockable, cardiac arrest, administration of epinephrine before the 2nd defibrillatory shock was associated with worse outcome. This was likely due to the cessation of high-quality CPR.
  • For in-hospital cardiac arrest, resuscitation should focus on high-quality CPR.

References: Andersen LW, Granfeldt A, Callaway CW, Bradley SM, Soar J, Nolan JP, Kurth T, Donnino MW, for the American Heart Association’s Get With The Guidelines?Resuscitation Investigators. Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. JAMA. 2017;317(5):494?506. doi:10.1001/jama.2016.20165

Podcast #263: Early Antibiotics in Sepsis

Author: JP Brewer, M.D.

Educational Pearls

  • After the first hour, every 1 hour delay in antibiotics in a patient with septic shock patient is associated with a 4% increase in mortality.
  • In patients with high suspicion for septic shock (fever and hypotension), antibiotics should be initiated ASAP. Rocephin (ceftriaxone) should be used for those with community-acquired sepsis, zosyn for nosocomial or IV-associated sepsis.

References: https://lifeinthefastlane.com/ccc/antibiotic-timing/

Podcast #260: Preoxygenation

Author: David Rosenberg, M.D.

Educational Pearls

  • Preoxygenation is done before rapid sequence intubation, and should be done even if SaO2 is at 100%.
  • Preoxygenation is done to fill the lungs with oxygen rather than ambient air, which is only 20% O2. While the patient is paralyzed, the O2-filled lungs will continue to oxygenate venous blood, buying you more time for intubation.  
  • BiPAP is an effective tool for pre-oxygenation.

References: https://lifeinthefastlane.com/ccc/preoxygenation/