This is a recording of the first EMCrit Live episode. Hope you enjoy.
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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I’m a Critical Care Paramedic and I spend 99% of my time in Pediatric Critical Care. We see a lot of pediatric DKA, often presenting with pH as low as 6.8. I can’t speak for the rest of the pediatric world, but in my facility we never use sodium bicarbonate with these patients. The profound metabolic acidosis in these patients is caused by ketones and lactate. In order to halt the production of ketones and lactate and facilitate their metabolism, the patient must be appropriately fluid resuscitated and started on an IV infusion of insulin (never give kids an IV… Read more »
Rebecca, great to hear that some places are not treating their peds DKA with bicarb.
Love the concept of the live show. Would have loved to chime in with a question, but my shift ran late and I just missed-out. Looking forward to the next one…
thanks Vince, we’ll get you next time.
Hi Scott.congratulations on the live show. Great range of questions and good discussion. I look forward to the next one and hopefully will be able to attend it!
you know I’d love to have you , my friend.
The acute versus chronic atrial fibrillation exacerbation is a very important topic I often see in the prehospital arena. Paramedics are usually not taught to appreciate this distinction. Was glad to hear the diltiazem slow-drip method was preferred!
I think a future podcast on the acute vs. chronic topic, contrasted to your classic “crashing af patient” podcast, would be very helpful!
great idea, Christopher.
Hey Scott, wanted to say thanks for the live show. Really like the format. Wish I could have been off in time to participate. Cant wait for the next one.
I will give a ton of advanced notice next time
The first question about ultrasound guided central lines was a good one and represents a common problem. Basically there are four ways to use ultrasound to assist in placing venous lines. For all of them you should first do a scan of the area and confirm that the ‘vessel’ you want to cannulate is indeed a vessel, is a vein and is patent. Then you can: 1) blindly access the vein you’ve found 2) as above but with the probe held over the vessel insertion point so that the last part of the needle’s path is visualised, this is Scott… Read more »
In-plane longitudinal is wonderful so long as the right vessel is in-plane. As ultrasonographers gain experience, this becomes the preferred technique as you mention.
Great show Scott, you see amazing with your commitment and passion for knowledge and education… I wanted to share in more detail the out plane technique as it did not sound clear cut on the programme if I may please… Essentially, using US you work out where you want the needle enter the vessel, then back off some distance and make the entry point into the skin still some distance away and perpendicular to the axis of the probe, hold the probe steady until you see the echogenic tip of the needle on the screen.. From there, slide the probe… Read more »
Agree and thanks for writing these down here. This is exactly how I put in peripheral IVs. Only problem with this in the neck is that the spot of entry of the needle into the vessel may not be as favorable an anatomy as where you started the skin entry. SO if you go in this direction, I would recommend scanning a few inches down on the IJ before you start to make sure the vessel is big in its entire length so that when the needle is actually about to hit the IJ, there is a clear path into… Read more »
Probably not the best place to put a request in, my apologies before hand. Could you please share in one of your podcasts some pearls on central line /artline placement in cardiac arrest/CPR. With CVC it is probably easier as you can just go IO. I vaguely recall you talking about it in your earlier podcasts, but there was nothing specific in detail. specifically at what point in time you would start seriously thinking about it and how hung up on it (I.e. how obsessed with it) would you be. Thanks.
the only tip at this stage is probably not to do it. it is dangerous and leads to needle sticks and patient trauma. wait till the patient gets a pulse. Meds prob. don’t do much, so obsess about good CPR instead of access.