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Critical Concepts

8 Dec, 5 tweets, 1 min read

Michae Levy on refractory VF: resuming immediate compressions after a defibrillation shock may in some cases induce refibrillation after initial (unnoticed) ROSC, due to the mechanical stimulus. #CCPRFSummit2021

Double sequential defibrillation may work, but just changing the vector (moving pads) may work as well.

“Refractory VF is rare. Recurrent VT is common.”

Maybe in some cases of apparent persistent VF (did ETCO2 bump? does a see-thru ECG suggest a rhythm?) we should pause post-shock to assess for a rhythm.

(See-through tech a la Zoll or newer Lifepaks may still not tell the whole story, as many rhythms may have their transient conversion so early after shock it occurs during the peri-shock filtering phase when telemetry is windowed out to avoid the shock itself.)

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@critconcepts

9 Dec

Jonathan Dresner on sudden cardiac arrest among athletes: most common source sports #CCPRFSummit2021

UW offers free online modules to educate clinicians on performing ECG screening for athletes uwsportscardiology.org/e-academy/ecg-…

(Spelling correction: Drezner)

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Critical Concepts

@critconcepts

31 Jan

Daniel Dante Yeh: In first 7 days of critical illness., hypocaloric (<70%) nutrition should be used, can advance to 80-100% after day 3. Use indirect calorimetry if you can. #CCC50

Use high-protein, hypocaloric feeding in obese patients to preserve lean mass while not overfeeding. If 30-50 BMI use 11-14 kcal/kg actual bodyweight, if BMI >50 use 22-25 kcal/kg of ideal bodyweight.

Generally use normal protein goals for kidney failure. If on CRRT, however, need to account for loss of aminos in the membrane, may be ~15-17%.

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Critical Concepts

@critconcepts

31 Jan

John Teerlink: Cardiac calcitropes (catecholamines, PDE3 inhibitors) increase contractility, ischemia, arrhythmias, mortality. We use them anyway because it's what we've got. #CCC50

OPTIME-CHF: Milrinone for CHF exacerbation when NOT requiring inotropes. No clinical benefit but trend for more MI/death and significant increase in arrhythmias and hypotension.

OptimaCC: epi vs norepi in cardiogenic shock in MI: no difference in change in cardiac index, but discontinued for harm in epi group (tachycardia and increase in refractory shock). So maybe use norepi?

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Critical Concepts

@critconcepts

31 Jan

Xavier Monnet: CNPN doesn't work for fluid responsiveness because it ignores the shape of the Starling curve, which varies by patient. You can't get the intersection of two lines if you don't know one of them. #CCC50

"Mini" fluid challenge (100-150ml) avoids as much overload if it proves negative, but requires very sensitive markers of cardiac output. Maybe pulse counter analysis...

PPV, SVV Uses the respiratory cycle as an intrinsic fluid challenge. Automatically measured by some bedside monitors. No good in arrhythmias, spontaneous breathing, low lung compliance or tidal volumes (eg ARDS), so only works out in about 20% of ICU patients.

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Critical Concepts

@critconcepts

29 Jan

Finally found a PPE regimen that seems to work well. This is the Envo mask (envomask.com) and the Wiley-x SG-1 goggles (sporteyes.com/wiley-x-ssg-1.…). A few notes (thread): #medtwitter #FOAMcc #COVID19

1. The goggles are not 100% sealed and have small vents along the sides. However, I do not think a 100% seal is necessary, and would be an incredible fog-creator. The Wileys are also pricey; consider these, almost as good (amazon.com/gp/product/B00…) but don't seal quite as well.

2. Any goggles, regardless of coating, will fog. Most important is a good mask seal, then use an anti-fog treatment. I found sprays to be a bother, but wipes are good. Try: sporteyes.com/hilco-fog-bust…

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