LOST AND FOUND: APRIL

A few medical bits and pieces from around the net. This time Canada is moving forward on sorting and sieving ACS patients. Needle cric gets a revival. Dobutamine and adrenaline get a whipping.

Sending ACS patients home
Suspected Acute Coronary Syndrome patients are taking up a lot of space and resources in the ED’s and cardiac units. We all know those chest pain patients that doesn’t quite seem to be cardiac, but we still don’t feel sure enough to send them home. They might end up getting the full ACS treatment, ECG monitoring and two to three sets of troponins. And some of them end up with a constant fear of cardiac disease, even though no pathology was found. There must be a better way, both for patients and the hospital system. Surely, some of these patients can be sent home straight away, and even more of them after a short stay in the ER? Canada seems to think so:

Emergency Medicine Literature of Note: How Canada Does Chest Pain

Needle cric: Simplify your approach
Usually, in a can’t intubate can’t ventilate situation, your airway obstruction is only partial, and a needle cric makes a lot of sense to buy you time. Either for a new go at conventional intubation, or for setting up a proper tracheotomy – by needle or knife. And you don’t need the slightly complicated set-up with a oxygen tubing and a three way connector to hook it up to your big i.v. cannula catheter placed through the cricothyroid membrane. Just hold your oxygen tubing to the cannula hub for oxygenation, remove for expiration, and repeat. Read, see the video, and be sure to read the comments section. There’s a lot of gold there:

EMCrit.org: More from Minh Le Cong on Needle Cricothyrotomy

Central line tips and tricks
Just as you though you knew everything about placing a central line. Some neat tips and tricks.

MD Aware: Central line tips and tricks.

Whipping a dead horse? A left-right combo on inotropes
Dobutamine isn’t good for a failing heart. Sometimes you will have to pull dobutamine out to get the patient through the acute face, but you might want to think twice about it. Make sure all basic measures have been optimised. And consider your options: Intra-aortic balloon pump, or the ultimate solution: ECLS. Remember, ECLS can fix anything.

ResusME: Dobutamine for severe heart failure – more harm than good?

Adrenaline isn’t doing cardiac arrest patients any favours. But it helps keeping the medical team occupied and feel as if they’re doing something. I’ve also heard cardiologists complain about adrenaline ‘overdosing’. If they get a patient in cardiac arrest up to the cath lab for PCI, and the patient has received the guideline recommended adrenaline dose every 4 minutes, they usually see a coronary tree in vasospasm. It’s all contracted into tiny, fine vessels. Pretty hard to catheterise, not to mention perfuse with blood. I haven’t seen any data on that, but the cardiologist’s anecdotes fit in nicely with this adrenaline meta-analysis.

ResusME: Epinephrine in cardiac arrest reanalysed

BONUS:
Cliff Reid goes to South Africa and finds Simple emergency haemorrhage control using a Foley catheter in a deep wound, then inflate the catheter balloon with saline to exert internal pressure to stop the bleed. Probably superior outcome compared to a tourniquet for massive neck bleeds.

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