We believe that the ICU-patients, especially ventilated patients, are prone to having stress ulcers and one of the components of the daily ICU drill is to ensure that the patient is on ulcer prophylactics.
We do this despite how the incidence of stress-induced GI-bleeding has been steadily decreasing, possibly due to earlyer initiation of enteral feeding. We do this despite how studies have reported associations between proton pump inhibitors and ventilator-associated pneumonias and c. difficile infections. Therefore, as per our current guidelines, virtually all intubated ICU-patients are on proton pump inhibitors. A paper in Crit Care Med, however, could find no evidence of that actually benefiting patients. More>>
I found an editorial in BJA that describes an issue with succinylcholine I wasn’t really aware of. Butyrylcholinesterase (BCheE) hyperactivity. BCheE is the non-specific cholinesterase that rapidly hydrolyses succinylcholine in the blood so that only 10% of the injected drug eventually reaches the neuromuscular endplate. More>>
One of the most immediate ways to understand aortic stenosis, and how it affects blood pressure and the heart, is by watching a Transcatheter aortic valve implantation (TAVI) procedure. Catheters are placed in both the left ventricle (LV) and the aorta. The measuring of pressures in the left ventricle overlaid on the pressure in the aorta is telling. Especially seeing how they are equalised after getting a new aortic valve that restores free flow through the LV outflow tract.
Below, you’ll see the left ventricle pressures in yellow, and aortic pressures in red (colors represented both in the graph tracings and the numbers left of them). More>>
We traditionally use GCS to triage patients who sustained traumatic brain injury. Some previous studies have reported how the accuracy of using GCS decreases with increasing age. Specifically, the elderly present with a higher GCS than younger patients when suffering the same injury. A large study presented in EMJ confirms those findings. More>>
A paper in EMJ compares various methods for performing field amputations. I can’t say I ever had to do one myself. However, some of the people I work with have performed amputations on rapidly deteriorating entrapped trauma victims.
Most them have relied on the standard Gigli technique where they scalpel the soft tissues and cut the bone with the Gigli saw. Apparently it is painfully slow, especially as it is performed on a trauma patient that is super sick. One colleague recommends using the firemens’ pneumatic cutters. More>>
Transesophageal Echo (TEE) is a bit of a niche thing in the ultrasound world, and trying to get into TEE, I find it really hard to wrap my head around the probe’s position and the spatial relations with probe, the omniplane and the heart. TEE trainer to the rescue! More>>
A trial called ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage II), recently published in NEJM, is likely to temper the enthusiasm for aggressively lowering blood pressure in patients with intracranial bleeds. >>
Some years ago, while working for an air ambulance, me and an experienced paramedic responded to a pedestrian-vs-car accident. A young female was out driving when she had a flat tire. As she opened the rear compartment to get the spare tire, a second car slammed in. Our patient was wedged between the cars. More>>
We all know that there’s so much to learn from other professions whom, although working outside of healthcare, function in comparably unpredictable high risk, high pressure environments. This mutual cross-pollination enriches the way we think about and look at our own practice and gives us new perspectives on what it means to perform under pressure. And this time it’s got nothing to do with aviation. More>>
A fascinating case report was recently published in Resuscitation. A young female speleologist was avalanched in the polish Tatra mountains. As she had access to an air pocket and some degree of ventilation she didn’t to succumb to the asphyxiation that kills most buried avalanche victims. Instead, she was gradually cooled to a core temperature of below 17° C. More>>