Bike-mounted CPR/AED providers in Tokyo marathons: 100% survival from SCA among athletes possible if there is very rapid response. (I’m reminded here of John Hinds and his motorcycle work.)
Immediate post-arrest timeline
Basically normal breathing immediately after arrest is typical. This should NOT be considered a sign of a pulse. Current resuscitation guidelines to look for “normal breathing” do not apply in these witnessed athlete arrests.
Assume ALL SUDDEN COLLAPSE IN AN ATHLETE IS CARDIAC ARREST (until proven otherwise - but true sudden collapse usually is)! Forget seizure, syncope, etc.
Risk is higher among African Americans. Assumed to relate to genetic reasons, but much of the difference can be more directly linked to locale of upbringing - ie may be more due to socioeconomics than intrinsic medical causes.
Mortality is far higher at sporting events occurring outside of schools, presumably due to poorer readiness to provide CPR/AED
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I think the number one challenge here is dilation, because obesity forces you to stick using unfortunate depths and angles. Good tips in the thread, but here's my favorite, which solves most problems: *continuously* rack your wire as you dilate. (thread)
Many people will pin the wire with their off-hand as they dilate (good), and some will periodically wriggle it in and out (okay); it will "catch" on retraction if you're kinking your wire (dilating off-axis) and making an angle at the tip. But too late! It's already kinked.
Instead, the ENTIRE TIME you dilate, continuously move the wire in and out slightly. This gives CONSTANT feedback that your dilation is on-axis. As soon as you lose that railroad - usually from dilating too steep - you'll feel the resistance to retraction and can correct.
Allan Walkey on atrial fibrillation in ICU (#SCCM2023)
Arrigo 2015: cardioversion for secondary A-fib in ICU rarely works (43% remains sinus at 1hr, 23% at 24hr). Diltiazem was more effective at rate control than amio or digoxin.
Walkey 2016: Afib in sepsis? Association on outcome of BB vs CCB, BB vs digoxin, BB vs amiodarone compared. BB had slightly lower mortality than CCB.
Bosch 2021: BB achieved more HR reduction than amiodarone, CCB, and dioxin at 1hr (CCB was highest at 6 hours).
Davey 2005: magnesium was about as effective at rhythm control as amiodarone.
Remember untreated infection, volume status, presence of beta agonists.
Law 2022: phenylephrine vs norepinephrine for shock? HR difference was only about 2-6 only, even in the subgroup with RVR.
Kevin Betthauser on empiric anaerobic antibiotics in the ICU (#SCCM2023)
gut dysbiosis common in ICU patients. Gut integrity degrades. Reduction in firmicutes and bacteriodetes, increase in proteobacteria. Less commensals, more opportunistic infections.
In animal models, depletion of anaerobes increases susceptibility to bacterial PNA, lung injury, mortality. Preserving anaerobes by SDD associated with less VAP, less mortality. (Szychowiak 2022, Hammond 2022)
ATS/IDSA 2019 CAP guidelines: suggest not routinely covering aspiration pneumonia for anaerobes. Modern syndromes typically CAP organisms, not anaerobic. Kioka 2017, Marrin-Corral 2021, Brummitt 2022 - show anaerobic coverage is downtrending over past five years.
clear standard of care for bronchoconstriction, but mostly used for hypoxemic disease because it "can't hurt". Ehrmann 2013 European survey found 95% used them routinely in mechanically ventilated
BALTI trial: IV B-agonists for ALI improved resolution of alveolar edema and survival
Perkins 2014: salmeterol didn't improve ALI
BALTI-2: salbutamol, stopped for harm
Routine nebs create significant workload and disposable equipment burden
Device types vary by efficiency, but we use so much drug it likely doesn't matter - it gets delivered.
Shelby Yaceczko on nutrition in critical illness + obesity (#SCCM2023)
malnourished inpatients have 3.4x risk of in-hospital death, but only 2.7% of patients with coded malnutrition actually receive enteral nutrition in the hospital.
malnutrition in ICU associated with length of stay, higher cost of care. ASPEN did a value analysis, shows nutrition support saves money (projected $222 million yearly Medicare savings).
ASPEN 2021 guidelines:
1. How much should you give? No difference between high and low levels of nutrition. Give 12-25 kcal/kg BW in first 7-10 days of ICU stay. (Old recs: depended on disease and malnutrition risk.)
Bethany Shoulders on Pharmacotherapy in critical illness + obesity (#SCCM2023)
Absorption: may be reduced both enteral and subq
Distribution: Increased
Metabolism: may decrease
Excretion: Often increased
B-lactams (inc. cephalosporins, meropenem, pip/tazo): good data on impact of obesity. more treatment failure, longer hospitalizations, risk of cefepime neurotoxicity. Use monitoring! Target 40-100% free time >MIC.
Anticoagulation (enoxaparin, heparin): Use higher dose for prophylaxis. No dose cap for weight-based dose of enoxaparin. May not need heparin dose increase unless BMI >50. For therapeutic heparin, slight preference to adjusted BW + no cap.